Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264531 Renewal 04/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Support Professional #2's date-of-hire is 3/11/25. The agency completed a Pennsylvania criminal history check on 3/11/25, revealing a final report of criminal history involvement. However, the agency did not provide documentation of a criminal record review outlining their consideration for hiring Direct Support Professional #2 based on the following factors: the nature of the crime; the facts surrounding the conviction; the time elapsed since the conviction; the evidence of Direct Support Professional #2's rehabilitation; and the nature and requirements of the job.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. Documentation of a criminal record review will be completed. 05/31/2025 Implemented
6400.62(a)On 4/15/25, at 11:29 AM, the following poisonous substances were found unlocked underneath the bathroom sink located in the home's basement: a one-quart, eight-ounce bottle of Pine Glo Kitchen and Bathroom Cleaner Pine Glo and a 24-fluid ounce bottle of Lysol Lime and Rust Toilet Bowl Cleaner. Individual #1 is not assessed safe with poisonous materials according to their current assessment completed on 11/1/24.Poisonous materials shall be kept locked or made inaccessible to individuals. The poisonous materials listed above were immediately placed in a locked storage cabinet. 05/31/2025 Implemented
6400.64(a)On 4/15/25, at 10:59 AM, underneath the refrigerator's bottom left crisper drawer and inside the base of this drawer were several black particles of food. At the base of the refrigerator's interior located in front of the crisper drawers were black and brown food spills and debris. The shelf atop the crisper drawers in the refrigerator was covered with several white, crusted liquid spills. The face of the bottom shelf inside the freezer door contained a brownish food splatter. The base of the freezer's interior contained several food crumbs. On 4/15/25, at 11:00 AM, the oven's interior base and interior glass door were covered significantly in blackened grease, white powdery substances, and chard food particles.Clean and sanitary conditions shall be maintained in the home. The refrigerator and oven have been thoroughly cleaned. 05/31/2025 Implemented
6400.66On 4/15/25, at 11:11 AM, the lighting in the walk-in cooler room located in the home's basement was inoperable. At 11:14 AM, there was no lighting fixture or sufficient nearby lighting source located outside of the basement's only exterior door. At 11:49 AM there was no lighting fixture or sufficient nearby lighting source located outside the exterior swing door of the home's detached garage.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A light bulb was replaced in the home's basement walk-in cooler room and is now operable. A lighting fixture has been installed outside the garage door and is operable. An electrician is in the process of installing a lighting fixture outside of the the basement door and will be operable within a week. 05/31/2025 Implemented
6400.72(c)On 4/15/25, at 11:05 AM, the exterior storm door located on the home's side exit leading from the kitchen to the driveway did not have an operable doorknob or lock. Outside doors shall have operable locks.A new doorknob was purchases to replace the broken storm door knob. 05/31/2025 Implemented
6400.85(b)On 4/15/25, at 11:50 AM, there were steps leading to a small platform deck that is level with the top threshold of the above-ground pool located in the home's side yard. However, the pool was not enclosed by a fence, railing, or gate to render it inaccessible when the pool is not in use.An aboveground swimming pool that is under 4 feet in height shall be made inaccessible to individuals when the pool is not in use.The above ground pool has been removed. 05/22/2025 Implemented
6400.111(e)On 4/15/25, at 11:35 AM, the only fire extinguisher located on the home's third floor was inaccessible, as it was located in the vacant bedroom with a door equipped with a lock requiring a key to enter from the outside. A fire extinguisher shall be accessible to staff persons and individuals. The locking doorknob has been replaced with a non-locking door knob. 05/22/2025 Implemented
6400.141(c)(1)Individual #1's physical examination dated 12/18/24 did not have the individual's previous medical history as part of the physical.The physical examination shall include: A review of previous medical history. A previous medical history will be attached to the individuals physical. 05/31/2025 Implemented
6400.181(e)(10)Individual #1's assessment dated 11/1/24 did not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history. A lifetime medical history will be added to the assessment. 06/20/2025 Implemented
6400.214(b)Individual #1's most current records were kept at the home: Individual Support Plan, Restrictive Procedure Plan, assessment, a physical examination, a dental examination, dental hygiene plan, an applicable psychological evaluation, and incident reports. During an interview, Chief Executive Officer/ Program Specialist #1 revealed that Individual #1's records are kept at Chief Executive Officer/ Program Specialist #1's own home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Copies of the ISP, Restrictive Procedure Plan, assessment, a physical examination, a dental examination, dental hygiene plan, an applicable psychological evaluation, and incident reports will be kept at the home. 05/31/2025 Implemented
6400.246100.484(d)(1) requires that standard toiletries, towels, and bedding are included in the Room and Board rate charged to Individual #1. Individual #1's Room and Board Contract, dated 1/1/25, indicates that Individual #1 pays $712.15 for both room and board. However, Individual #1's financial ledgers for January 2025, February 2025, and March 2025 included the following entries and corresponding receipts, indicating that Individual #1 purchased their own bedding for which Individual #1 already pays in their room and board contract: On 1/13/25, a purchase totaling $73.65 was made at Walmart for bedding; on 24/25, a purchase totaling $27.48 for bedding at Walmart; and on 3/19/25, a purchase totaling $106.85 for bedsheets and a blanket at Walmart.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The purchases for bedding totaling $207.98 have been reimbursed back to the individual's bank account. 05/22/2025 Implemented
6400.32(h)On 4/15/25, Individual #1's clothing was kept in storage bins located in the home's medication storage room. During an interview, Chief Executive Officer/ Program Specialist #1 revealed that Individual #1's clothes were not kept in their bedroom because Individual #1 would tear them apart. This is an infringement upon Individual #1's right to privacy and personal possessions, as this arrangement was not documented in Individual #1's current assessment, completed on 11/1/24, current Individual Support Plan, last updated 3/16/25, or current Restrictive Procedure Plan, last updated 2/13/25. On 4/15/25, at 11:03 AM, the window located in the full bathroom located on the home's main floor did not contain curtains, blinds, drapes or any type of covering preventing a view from the outside to uphold Individual #1's right to privacy.An individual has the right to privacy of person and possessions.A frosted window covering has been adhered to the individuals bathroom window to maintain personal privacy. The individual's restriction to clothing due to O.C.D will be updated and documented in the assessment, ISP, and RPP. 06/20/2025 Implemented
6400.52(c)(4)Direct Services Worker (DSW) #1 did not have the annual required training of recognizing and reporting incidents for annual calendar training year dated January 1, 2024, to December 31, 2024.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.DSW #1 has completed training of recognizing and reporting incidents. 04/28/2025 Implemented
6400.165(b)Individual #1 does not have a current prescription for the following medications: Diphenhydromine HCI 25 mg, Diphenhydromine HCI 25mg with Phenyleprine HCI 10mg, THC Gummies,, and Super Nu-thera (multi vitamin).A prescription order shall be kept current.Prescriptions for Diphenhydramine HCI 25 mg and THC gummies have been written by the individual's PCP. The individual's PCP discontinued Diphenhydamine HCI 25 mg with Phenyleprine. He also discontinued Super Nu-thera and replaced it with a prescription for equate men's multivitamin gummies. 05/05/2025 Implemented
6400.166(a)(4)On 4/15/25, Individual #1's April 2025 Medication Administration Record indicated different medication names for the following prescribed medications than what was indicated on their corresponding physician's orders, and the actual medications: Super Nu-Thera OTC---Take 1 capsule by mouth 2 times a day (multivitamin)---was written on the Medication Administration Record. Super Nu-Thera OTC---Take 1 capsule by mouth 2 times a day---was indicated on the physician's orders. Super Nu-Thera with P5P---Take two capsules daily or as directed by physician---was listed on the medication bottle. DMG 125 mg---Take 1 capsule by mouth 2 times a day (multivitamin)---was written on the Medication Administration Record. Diphenhydramine HCI 25 mg---Take as indicated on bottle label---was indicated on the physician's orders. DMG (Dimethylglycine) 125 mg---Take one capsule daily or as directed by physician---was listed on the medication bottle. THC Gummies---Take 1 gummy twice daily for anxiety---was written on the Medication Administration Record. Shine Troches (50 mg THC/ 50 mg CBD)---For best results, place one piece between gum and check and allow to fully dissolve---was listed on the medication bag. The agency did not provide corresponding physician's orders for this medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The Medication Administration Record has been corrected. All current medications match the prescription label or Doctor's order. 05/05/2025 Implemented
6400.166(a)(5)On 4/15/25, the following of Individual #1's prescribed medications were missing the medication strength on their April 2025 Medication Administration Record: pro re nata, Milk of Magnesia, with administrative instructions as written on the physician's orders to "Take as indicated on bottle label"; Super Nu-Thera---Take 1 capsule by mouth 2 times a day (multivitamin); Cranberry---Take one capsule once a day for urinary health; THC Gummies---Take 1 gummy twice daily for anxiety; pro re nata, Gaviscon Liquid --Take 2 to 4 teaspoons up to 4 times daily as needed for gas. Individual #1's April 2025 Medication Administration Record indicated a different medication strength for the prescribed, pro re nata, Antacid Tablets (Calcium Carbonate---750 mg)---Take as indicated on label---as was listed on the medication itself that read, "Equate Antacid Tablets Ultra Strength (Calcium Carbonate 1000 mg)." Individual #1's April 2025 Medication Administration Record indicated a different medication strength for the prescribed, DMG 125 mg---Take 1 capsule by mouth 2 times a day (multivitamin)---as was indicated on the corresponding physician's orders that read: "Diphenhydramine HCI 25 mg---Take as indicated on bottle."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The Medication Administration Record has been corrected. 05/05/2025 Implemented
6400.166(a)(8)On 4/15/25, the following of Individual #1's prescribed medications were missing the route of administration on their April 2025 Medication Administration Record: Cranberry---Take one capsule once a day for urinary health; Melatonin---5 mg---Take 1 tablet once a day to aid sleep; THC Gummies---Take 1 gummy twice daily for anxiety; and pro re nata, Gaviscon Liquid --Take 2 to 4 teaspoons up to 4 times daily as needed for gas.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The Medication Administration Record has been corrected. 05/05/2025 Implemented
6400.166(a)(11)On 4/15/25, the following of Individual #1's prescribed medications were missing the purpose or diagnosis on their April 2025 Medication Administration Record: Diphenhydramine HCI 25 mg---with administrative instructions as written on the physician's orders to "Take as indicated on bottle"; Diphenhydramine HCI---25 mg with Phenylephrine HCI 10 mg with administrative instructions as written on the physician's orders to "Take as indicated on bottle"; pro re nata, Acetaminophen 500 mg, with administrative instructions as written on the physician's orders to "Take as indicated on bottle"; and pro re nata, Antacid Tablets (Calcium Carbonate---750 mg) with administrative instructions to "Take as indicated on label." The agency did not provide corresponding physician's orders for this medication.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.The Medication Administration Records have been corrected and physicians orders have been written for all current medications. 05/05/2025 Implemented
SIN-00242884 Renewal 04/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 4/17/24, at 12:21 PM, the hot water temperature tested at 131.5 degrees Fahrenheit at the bathtub in the only bathroom in the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. The thermostat on the hot water tank was turned down and checked so that the water will not exceed 120 degrees. The safety stop on the bathtub water valve was also check for proper adjustment. 04/23/2024 Implemented
SIN-00224721 Renewal 05/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's self-assessment was completed on 3/23/2023, the agency's Certificate of compliance expires 4/23/2023 and the last annual inspection by the department was 5/26/2022.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. ML Services Corp. will complete a valid self-assessment within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The date will be tracked using Google Calendar. The Program Manager will ensure that it is completed within the appropriate time frame. 05/26/2023 Implemented
6400.15(b)The agency's self-assessment, completed on 3/23/2023, was conducted utilizing the Licensing Inspection Instrument Scoresheet, last updated by the department on 7/12/2011.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.ML Services will use the updated Licensing Inspection Instrument to complete its self-assessment. 05/26/2023 Implemented
6400.52(c)(2)Chief Executive Officer/Program Specialist #1 did not receive training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the annual training year 1/1/2022 - 12/31/2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The Chief Executive Officer completed training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on May 18, 2023. 05/26/2023 Implemented
6400.52(c)(4)Chief Executive Officer/Program Specialist #1 did not receive training in recognizing and reporting incidents during the annual training year 1/1/2022 - 12/31/2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The CEO completed training in recognizing and reporting incidents on May 22, 2023. 05/26/2023 Implemented
SIN-00205430 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #3 had a physical examination completed 2/4/19 and then again 6/24/21. 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. All staff had physical examinations completed in 2021. DSW#3 will complete an annual physical no later than June 30, 2022. Staff physicals will be completed annually. Staff will be reminded to complete the physicals using the Agency physical form by June 30th annually. The program specialist will conduct a training on the importance of completing employment physicals. 06/30/2022 Implemented
6400.151(c)(2)Direct Service Worker #3 had Tuberculin skin testing by Mantoux method with negative results completed 2/6/19 and then again 6/24/21. The physical examination shall include: 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. All staff had Tuberculin skin testing by Mantoux method with negative results in 2021. DSW#3 will complete Tuberculin skin testing by Mantoux no later than June 30, 2022. All Staff will have Tuberculin skin testing by Mantoux method annually. Staff will be reminded to complete the TB test using the Agency physical form by June 30 annually. The program specialist will conduct a training on the importance of completing TB Tests. 06/30/2022 Implemented
6400.51(b)(5)Direct Service Worker #2's , date of hire 1/10/22, orientation did not include Job knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.DSW#2 will have job-related knowledge and skills orientation by June 30, 2022. All newly hired staff will have orientation including job-related knowledge and skills within 30 days upon hire. A training file has been created that includes job-related knowledge and skills. 06/30/2022 Implemented
6400.52(c)(1)Chief Executive Officer/Program Specialist #1 did not receive training in community integration, individual choice and supporting individuals to develop and maintain relationships during training year 1/1/21-12/31/21. Direct Service Workers #3, #4 and #5 did not receive training in person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during training year 1/1/21-12/31/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The program specialist will complete community integration, individual choice, and supporting individuals to develop and maintain relationships trainings by 6-30-22. DSW#3,4, and 5 completed the trainings on 2-25-2022. 06/30/2022 Implemented
6400.52(c)(3)Chief Executive Officer/Program Specialist #1 and Direct Service Workers #3, #4 and #5 did not receive training in Individual Rights during training year 1/1/21-12/31/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The program specialist completed Individual Rights training on June 2, 2022. DSW#3,4, and 5 completed Individual Rights training on 2-25-2022. 06/30/2022 Implemented
SIN-00187087 Renewal 04/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(f)During the inspection on 4/30/2021, while reviewing Individual #1's April 2021 financial record, it was stated by Chief Executive Officer #1, that staff pay for items for the individual out of their own money and then submit the receipt to the Chief Executive Officer and are reimbursed with Individual #1's money.There may be no commingling of the individual's personal funds with the home or staff person's funds. A financial log has been created to account for Individual #1's money. The log show's deposits and withdrawals. Receipts of $15.00 and over will be kept on file. Staff will be trained to use the log by May 31, 2021. 05/31/2021 Implemented
6400.106A furnace inspection was completed 10/22/2019 and then again 11/24/2020.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. A tracking system will be created to ensure furnace inspections are completed at least annually. This year the Program Manager will call a professional cleaning company (HVAC service) no later than October 8, 2021. The tracking system will be created by June 30, 2021. 06/30/2021 Implemented
6400.141(c)(6)There is no record of a Tuberculin skin test by Mantoux method for Individual #1.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. A TB X-ray was ordered on May 3, 2021 by Doctor Brian Los, Oil Valley Internal Medicine, Titusville PA for Individual #1. Staff will take Individual #1 to Titusville Area Hospital by May 31, 2021 to have the X-ray taken. 05/31/2021 Implemented
6400.151(b)The most recent physical examination for Direct Service Worker #2 was completed 9/10/2018. The most recent physical examination for Program Specialist #1 was completed 2/21/2013. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Direct Service Worker #2 completed a physical on May 6, 2021. Program Specialist #1 completed a physical on May 10, 2021. Physicals for Direct Service Workers and Program Specialist will now be done annually. 06/30/2021 Implemented
6400.151(c)(2)The most recent Tuberculin skin test by Mantoux method for Program Specialist #1 was completed 1/25/2017. The most recent Tuberculin skin test by Mantoux method for Direct Service Worker #2 was completed 9/12/2018. The physical examination shall include: 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. A Mantoux Tuberculin skin test was completed by Program Specialist #1 on May 12, 2021. A Mantoux Tuberculin skin test was completed by Direct Service Worker #2 on May 8, 2021. Both test were negative. 05/12/2021 Implemented
6400.46(b)The most recent fire safety training for Program specialist #1 was completed 1/4/2015. The most recent fire safety training for Direct Service Worker #2 was completed 9/13/2018.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Program Specialist #1 has completed fire safety training on 05/01/2021. Direct Service Worker #2 has completed fire safety training on 04/30/2021. 06/30/2021 Implemented
6400.46(d)The most recent training for Direct Service Worker #2 in cardio-pulmonary resuscitation was completed 1/23/2019.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.On 05/03/2021 a training link for cardio-pulmonary resuscitation was sent to Direct Service Worker #2. Direct Service Worker #2 has been instructed to complete the training by 05/31/2021. The Program Manager will follow-up to ensure Direct Service Worker #2 completes the training by 05/31/2021. 06/30/2021 Implemented
6400.166(a)(5)Individual #1 is prescribed Melatonin 5mg with instructions to take 1 tablet once daily. The April 2021 medication administration record did not include the strength for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The medication administration record for Individual #1 was corrected on 04/30/2021. 05/31/2021 Implemented
6400.194(a)Individual #1's individual service plan, last updated 4/07/2021, states the "individual does not tolerate having curtains on the windows or having a door on his bedroom. If they are installed the individual will tear them down. The individual should not have any furniture with removable parts such as dresser drawers because he may remove them and use them as weapons." During the inspection on 4/30/2021 Direct Service Worker #3 stated the individual clothes are kept in the kitchen and medication room due to the individual destroying them. It was also confirmed during the inspection on 4/30/2021 that Individual #1 did not have curtains on the window in the bedroom, a door for the privacy in the bedroom, or a dresser. The home has not used a human rights team prior to implementing the restrictive procedure.If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section.A restrictive procedures plan will be created for, curtains, bedroom door, dresser/furniture, and storage of clothes by 05/31/2021. Because curtains are unsafe for Individual #1, the windows are tinted; however, a solution will be found to cover half of the window(s) to ensure privacy. The Program Manager has contacted the United Community Independence Program (UCIP) in Meadville, PA to assist in creating the restrictive procedures plan. 06/30/2021 Implemented
SIN-00153962 Renewal 04/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(10)(iii)Individual #1's record did not include ISP reviews or revisions.Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: ISP revisions.ML Services Corp. has discontinued using a contracted Program Specialist due to work not completed because of scheduling conflicts. Our Program Manager will take on the duties of Program Specialist and insure that ISP reviews/revisions are completed and documented. This change has been made and a monthly file review will be conducted to maintain compliance. [Immediately, the CEO or designee shall ensure the 2 most recent ISP reviews are completed and entered in to Individual #1's record. (AES,HSLS on 6/17/19) 06/14/2019 Implemented
SIN-00094305 Renewal 05/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)The physical examination for Individual #1, completed on 12/31/15, does not include physical limitations of the individual. The physical examination shall include: Physical limitations of the individual. An appointment has been scheduled for June 8, 2016 to have the individuals PCP complete the physical limitations section of the physical examination form. The Program Manager will train the Program Specialist to maintain physical examination records, and submit a training sign-in sheet by June 10, 2016. To ensure compliance the Program Manager will review the physical examination record before the annual exam is scheduled to check that all required information is included on the physical examination form. After the exam, the Program Manager will review the record to ensure the PCP has completed all sections of the physical examination form.[At the time of the appointment on June 8, 2016, Individual #1's physical examination was updated by the physician to include physical limitations of the individual. (AS 6/10/16)] 06/10/2016 Implemented
6400.141(c)(14)The physical examination for Individual #1, completed on 12/31/15, does not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Program Specialist will update the physical examination record to include medical information pertinent to diagnosis and treatment in case of emergency. The Program Manager will train the Program Specialist to maintain physical examination records, and submit a training sign-in sheet by June 10, 2016. A copy of the updated examination record will also be submitted. To ensure compliance the Program Manager will review the physical examination record before the annual exam is scheduled to check that all required information is included on the physical examination form. After the examination, the Program Manager will review the record to ensure the PCP has completed all sections of the physical examination form..[At the time of the appointment on June 8, 2016, Individual #1's physical examination was updated by the physician to include medical information pertinent to diagnosis and treatment in case of an emergency. (AS 6/10/16)] 06/10/2016 Implemented
6400.181(e)(2)The assessment for Individual #1, dated 11/6/15, does not include the likes, dislikes and interest of the individual. The assessment must include the following information: The likes, dislikes and interest of the individual. The Program Specialist will add the individual's likes, dislikes, and interests to the assessment, and the Program Manager will conduct a training with the Program Specialist on maintaining and updating assessments. The assessment will be updated and training will be completed by June 10, 2016. Copies of the updated assessment and a training sign-in sheet will be submitted by June 10, 2016. The Program Manager will monitor on a monthly basis to ensure that the assessment is updated regularly.[The program specialist updated Individual #1's physical on June 7, 2016 to include the likes, dislikes and interest of the individual. (AS 6/101/16)] 06/10/2016 Implemented
6400.181(e)(3)(i)The assessment for Individual #1, dated 11/6/15, does not include the individual's current level of performance and progress in acquisition of functional skills. The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. The Program Specialist will add the individual's current level of performance and progress in acquisition of functional skills to the assessment, and the Program Manager will conduct a training with the Program Specialist on maintaining and updating assessments. The assessment will be updated and training will be completed by June 10, 2016. Copies of the updated assessment and a training sign-in sheet will be submitted by June 10, 2016. The Program Manager will monitor on a monthly basis to ensure that the assessment is updated regularly, 06/10/2016 Implemented
6400.181(e)(3)(iv)The assessment for Individual #1, dated 11/6/15, does not include the individual's current level of performance and progress in personal needs with or without assistance from others. The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. The Program Specialist will add the individual's performance and progress in personal needs with or without assistance from others to the assessment, and the Program Manager will conduct a training with the Program Specialist on maintaining and updating assessments. The assessment will be updated and training will be completed by June 10, 2016. Copies of the updated assessment and a training sign-in sheet will be submitted by June 10, 2016. The Program Manager will monitor on a monthly basis to ensure that the assessment is updated regularly, 06/10/2016 Implemented
SIN-00079381 Renewal 05/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)The most recent Tuberculin skin testing by Mantoux completed for Individual #1 was completed on 1/5/2013.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. The Program Specialist will submit a plan for De-sensitization.[On 7/9/15, Program Manager submitted a copy of waiver and doctor order regarding the tuberculin skin test. If waiver is denied the program manager and program specialist will develop a plan for desensitization and submit it to the department via email to ascharpf@pa.gov (AS 7/9/15)] 06/19/2015 Implemented
6400.141(c)(9)The physical examination completed, 12/23/14 for Individual #1, date of birth 9/7/71, did not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. The Program Specialist will submit a plan for De-sensitization.[On 7/9/15, Program Manager submitted a copy of waiver and doctor order regarding the prostate examination. If waiver is denied the program manager and program specialist will develop a plan for desensitization and submit it to the department via email to ascharpf@pa.gov (AS 7/9/15)] 06/19/2015 Implemented
6400.171A bowl containing potatoes and a package of "Velveeta" cheese were unsealed in the refrigerator in the kitchen of the home. The cabinets across from the stove in the kitchen contained boxes and bags of snack foods alongside personal hygiene items including shaving gel, mouth wash, used toothbrushes, after shave liquid and sunscreen lotion. Food shall be protected from contamination while being stored, prepared, transported and served. Staff will be trained/retrained on proper food storage. [As per conversation with Program Manager on 6/22/15, the following additions were submitted to the Department on 7/1/15; Staff will be trained by July 31, 2015 on protecting food from contamination. The training will include safe food handling when transporting, preparing, and storing food. The program manager has been certified in food safety and will conduct the training. Program Manager will submit a copy of the training sign-in sheet after the training is completed, and receipts for purchase of food storage containers. (AS 7/9/15)] 06/19/2015 Implemented
6400.213(1)(i)The record for Individual #1 does not include the admission date, the height, weight, color of hair, color of eyes, identifying marks, the religious affiliation and a current, dated photograph. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The Program Manager will record the missing information in the individual's file. A copy will be E-mailed for review.[A copy of the a personal information sheet with the required information including a dated photograph was sent to and receivied by the department on 7/1/15. (AS 7/9/15)] 06/19/2015 Implemented
SIN-00058487 Renewal 06/11/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light over the basement stairs is dim and does not provide sufficient light to assure safety and avoid accidents.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A new light fixture will be installed per ch. 6400.66, and the Program Manager will be trained by a board member to conduct monthly walk through inspections to insure compliance with ch. 6400.66. The Program Manager will also train staff to report lighting issues to management. 06/22/2014 Implemented
6400.73(a)The handrail leading to the second floor office is loose and not well-secured. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The handrail has been corrected to comply with ch. 6400.73(a). The Program Manager will be trained by a board member to conduct a monthly walk through inspection to ensure compliance with ch. 6400.73(a). The Program Manager will also train staff to report issues with handrails to management. 07/31/2014 Implemented
SIN-00045505 Renewal 02/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)On 2/1/2013, there was no documentation to indicate the agency CEO completed 24 hours of training, relevant to human services or administration, on an annual basis. (Partially Implemented Adequate Progress; 5/8/13; CEM)(c) The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.The CEO will ensure that he has completed 24 hours of relevant training annually and that training documentation is kept on site. The CEO will be completing two trainings in May, CPR training has been completed(4 HRS),and I received my certificate for Medication Administration ¿ Trainer Course (6 HRS). I will schedule at least 48 HRS of training this year to correct the deficiency in training hours. I will provide a PDF file to show the upcoming scheduled trainings and the trainings I have completed. 04/01/2013 Implemented
6400.74On 2/1/2013, the stairways leading to the upper level of the home and basement level of the home did not have a non-skid surface. (Fully Implemented; 5/8/13; CEM)Interior stairs and outside steps shall have a nonskid surface. The stairs in question will have a nonskid surface applied before the end of March 2013. A picture will be provided once the repairs have been made. The Program Manager will ensure that this is completed. [The Program Manager will conduct monthly site inspections to ensure all physical site criteria is met regarding the 6400 regulations. In order to track physical site maintenance, a checklist will be prepared and completed by the Program Manager based on the results of the monthly physical site inspection. All physical site violations will be provided to the CEO for the purpose of correcting the violations. The CEO will be responsible for ensuring all physical site violations are corrected in a timely manner. The CEO will be responsible for ensuring the Program Manager is trained in regards to these responsibilities.] (CEM-5/8/13) 03/31/2013 Implemented
6400.82(d)On 2/1/2013, the bathroom on the main floor of the home did not have a door, partition, or curtain to ensure privacy. (Fully Implemented; 5/8/13; CEM)(d) Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. The bathroom door will be reinstalled before the end of March 2013. A picture of the repairs will be provided upon completion. The Program Manager will ensure this is completed. [The Program Manager will conduct monthly site inspections to ensure all physical site criteria is met regarding the 6400 regulations. In order to track physical site maintenance, a checklist will be prepared and completed by the Program Manager based on the results of the monthly physical site inspection. All physical site violations will be provided to the CEO for the purpose of correcting the violations. The CEO will be responsible for ensuring all physical site violations are corrected in a timely manner. The CEO will be responsible for ensuring the Program Manager is trained in regards to these responsibilities.] (CEM; 5/8/13) 03/31/2013 Implemented
6400.186(a)On 2/1/2013, there was no documentation to indicate that ISP reviews were conducted every 3 months for Individual #1. The following reviews were missing from the record: 4/12/12, 7/12/12, and 10/12/12. (Partially Implemented Adequate Progress; 5/8/13; CEM)(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. ISP reviews will be completed and documented every three months. Our Program Specialist was given training on completing ISP reviews on 3/1/2013. Documentation of the training will be provided to licensing. [The Program Manager will ensure that ISP reviews are completed and documented every three months. A tracking form will be prepared that outlines due dates for three-month ISP reviews and implemented upon completion of the next ISP review. A copy of the tracking form will be provided to licensing.] (CEM; 5/8/13) 03/01/2013 Implemented
6400.186(e)On 2/1/2013, there was no documentation to indicate that plan team members were notified of the option to decline ISP review documentation. (Partially Implemented Adequate Progress; 5/8/13; CEM)(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. A letter will be sent to plan team members noting the option to decline the ISP review. A copy of the letter will be provided to licensing. [The Program Manager will ensure that notification is sent and documented. The Program Specialist will be given training on completion of the declination form. Documentation of the training will be provided to licensing.] (CEM; 5/8/13) 03/31/2013 Implemented
SIN-00172491 Renewal 03/13/2020 Compliant - Finalized
SIN-00133970 Renewal 05/01/2018 Compliant - Finalized
SIN-00114310 Renewal 05/18/2017 Compliant - Finalized