Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00252968 Renewal 10/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(c)The back yard had old trash such as a toilet and a heater the needs to be removed.Trash shall be removed from the premises at least once per week. The toilet and heater were removed on 10/7/24. 10/07/2024 Implemented
6400.67(a)The vestibule floor and the kitchen floor leading to the back yard is warped and some there is damage that may cause a tripping hazard.Floors, walls, ceilings and other surfaces shall be in good repair. The vestibule and kitchen floor were replaced on 10/10/24. 10/10/2024 Implemented
6400.67(b)There is a very high step that leads to the backyard, which is potentially hazardous. Floors, walls, ceilings and other surfaces shall be free of hazards.The step was leveled on 10/11/24. It is no longer high or hazardous. 10/11/2024 Implemented
6400.68(b)The water temperature read 133 degrees in the bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted on 10/4/24. It is currently 87.5. 10/04/2024 Implemented
6400.81(k)(2)Individual One's mattress and box spring is on the floor. There is nothing in individual one's plan regarding the need to do so, therefore, there needs to be a bedframe, and a headboard purchased to support the bed.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The individual is unable to have a bed frame of headboard due to his history of self-injurious behavior. This has been added to his assessment. 10/11/2024 Implemented
6400.46(b)Youtube video was used to train staff one. The video was by a company called Fire Safety Compliance LLC. No source was provided to demonstrate that the company or person in the video met any of the following qualifications: It is the provider's responsibility to demonstrate that this training was provided by a qualified fire safety expert; a safety expert must be one of the following: · Member of a local fire department, · Fire protection engineer, · State-certified fire protection instructor, · College instructor in fire science, · Graduate of a county or State fire school, · Volunteer trained and certified by a county or Commonwealth fire school; or · Insurance company loss control representative.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All staff will now be trained on fire safety through Relias. Relias is accredited through the National Alliance of Direct Support Professionals (NADSP). 10/09/2024 Implemented
SIN-00232573 Renewal 10/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff #1 did not have a biennial tuberculosis screening. The screenings occurred in 3/2021 and 6/2023. Also, the results for the 6/2023 screening were not available for review during the inspection. 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. The TB test was completed on 10/23/23. The test was done late due to a dearth of serum needed for the test. 10/10/2023 Implemented
6400.52(c)(2)Staff #1 did not have annual training in the area of prevention, detection and reporting of abuse.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 training for prevention, detection, and reporting of abuse was completed on 10/10/23. 10/10/2023 Implemented
6400.52(c)(3)Staff #1 did not have annual training in the area of individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Individual Rights training was completed on 10/10/23. 10/10/2023 Implemented
SIN-00212856 Renewal 10/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 arrived with the company on 11/10/22 however the first completed annual physical exam for Individual #1 did not occur until 3/3/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. We received a physical from the hospital that Individual 1 was discharged from that we felt was sufficient; however, it was not completed on the ODP approved annual physical form. We have a move-in checklist that covers the annual physical be needed prior to move-in, but, as I mentioned, we thought the hospital's physical was acceptable. 10/07/2022 Implemented
6400.181(e)(8)The annual assessment for individual #1 dated 12/15/21 does not state ability to evacuate in the event of a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. The annual assessment has been revised and Individual 1's ability to evacuate in a fire has been added to the home safety section of the document. 10/10/2022 Implemented