Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285244 Renewal 03/17/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65At 2:17 PM on 3/17/26, the half-bathroom located in the home's basement did not contain an installed exhaust fan or any other mechanical ventilation system. The bathroom's only window was stationary and did not open.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The toilet and sink have been removed and it is just an empty storage room now. 03/27/2026 Implemented
6400.82(f)At 2:17 PM on 3/17/26, the half-bathroom located in the home's basement did not include a trash receptable, soap, and individual clean paper or cloth towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The bathroom did not have toilet paper, soap, clean paper or cloth towels, or a trash can. This to ensure all hygiene and materials related to it is available to the individual while using the bathroom. This was an unused bathroom so the toilet and sink have been removed. It is no longer a bathroom and just an empty room in the basement. 03/27/2026 Implemented
6400.106The home's furnace was inspected on 9/18/24, and then again on 11/10/25. In addition, the furnace inspection invoices provided for 9/18/24 and 11/10/25 did not include documentation that the home's furnace was also cleaned.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. DTE's CEO Spoke with Cochran's Heating and Air (provider of furnace inspection and cleaning) to investigate why this occurred. We were late in the scheduling for this past year due to their office changing personnel and an oversight with our renewal being due. We are currently renewed for another 3 year contract. In addition we requested that Cochran's update their printouts to reflect what cleaning was done. They agreed to do so and emailed us an update of the previous inspection paperwork for our records. 03/23/2026 Implemented
6400.50(a)Individual #1 completed annual fire safety training on 4/29/24, and then again on 4/29/25. However, documentation for both of these fire safety training records did not include the trainer who facilitated these sessions. Direct Service Worker #3's date-of-hire is 6/1/25. On 5/31/25, Direct Service Worker #3 completed orientation training on job-related knowledge and skills regarding reviews of Individual #1's behavior support plan and service plan. However, this aforementioned training neither documented the trainer or facilitator who conducted the session, nor the training's length, as the corresponding fields were left blank. On 7/2/25, Direct Service Worker #4 completed annual training for the 2025 calendar year on job-related knowledge and skills regarding reviews of Individual #1's behavior support plan and service plan. However, this aforementioned training neither documented the trainer or facilitator who conducted the session, nor the training's length, as the corresponding fields were left blank.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Individua l#1's fire safety trainings along with DSW#3's and DSW #4's ISP/ Behavioral support plan for Individual#1 training sheets are updated with the trainer's signature and the length of the ISP training. 03/25/2026 Implemented
6400.52(c)(2)Direct Service Worker #4 did not complete annual training for the 2025 calendar year in the required content area of the prevention, detection and reporting of abuse, suspected abuse, and alleged 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.DSW #4 was out of compliance due to completing The prevention, detection, and reporting of Abuse and alleged abuse by 1 day on the Relias platform. The training encompassing this area will be moved to and earlier month to ensure completion within the calendar year. 03/25/2026 Implemented
SIN-00267020 Renewal 05/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At 12:36PM, an unlabeled spray bottle containing an unidentifiable liquid and a spray bottle containing a bluish gray liquid with "Do not use on mirrors" handwritten on masking tape on one side and "antibacterial bathroom" handwritten on the other side, were stored with a variety of other cleaning supplies.Poisonous materials shall be stored in their original, labeled containers. Admin 1 removed the unlabeled bottles and the concentrated cleaning chemical from the site on 5/28/2025 All agency staff received a retrain on poisons (55 PA Code 6400.62 Physical site checklist updated to highlight the infraction for staff to check monthly Admin 1 will do quarterly checks to ensure all poisons are labeled and in their original container 06/06/2025 Implemented
6400.74At 12:13PM, the outside steps from the porch in the rear of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Admin 1 added nonskid strips to the stairs on 5/29/2025 Physical site checklist updated with inclusion of out door stairs- check for deterioration of non skid strips and notify Admin 1 if need replacing. This form is turned in at the end of every month and is filled in by the staff whose shift falls on the last day of the month. 06/06/2025 Implemented
6400.80(b)At 12:13PM, the handrails, on either side of the six outside steps in the rear of the home, were overgrown with shrubbery obstructing safe use of the handrails posing a falling risk. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Shrubs were immediately removed by Admin 1 and Program specialist on 5/29/2025 Staff retrained on Fire drills which included a discussion of the importance of clear egress for our individual's safety. 06/06/2025 Implemented
6400.101At 10:45AM, the front door was equipped with a chain lock posing an obstructed egress when engaged. At 12:04PM, the outside door in the garage was equipped with a foot operated latch lock at the bottom an obstructed egress when engaged. At 12:10PM, the basement door was equipped with a sliding bolt lock posing an obstructed egress when engaged. In addition, at 12:10PM, the four outside steps and the outside area at the basement door egress was obstructed by and contained multiple tripping, slipping and falling hazards to include a garden hose strewn across the four outside steps, overgrown plants, dirt, leaves, sticks, mossy areas, a loose red brick and a full size portable basketball hoop.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Chain lock removed by Program Specialist on 5/28/2025. Foot latch removed by Program specialist on 5/28/2025. Admin 1 removed the sliding bolt on basement door on 5/28/2025. Admin 1 removed debris, moss and overgrown plants from basement door egress on 5/29/2025. Admin 1 moved hose to far end of the house where the water nozzle is and placed on a hose stand on 5/29/2025. Basket ball hoop was removed by Program Specialist on 5/29/2025 06/06/2025 Implemented
6400.110(b)At 12:15PM, the closest smoke detector was twenty feet-four inches from Individual #1's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Program specialist added a new smoke detector in the hallway directly outside of individual 1's bedroom door(within 6 feet) 05/29/2025 Implemented
SIN-00226726 Renewal 06/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's 8/2/22 physical examination did not address emergency info pertinent to diagnosis and treatment in case of emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Staff will have physician address individuals medical info pertinent to diagnosis and treatment in case of emergency on 08/02/22 07/07/2023 Implemented
SIN-00208531 Renewal 07/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a tuberculin skin testing completed on 1/28/2020 and then again on 2/23/2022.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 CEO updated both the physical form and the appt/immunization tracking form to be clearer on when these tests are needed. The Program Specialist created a retraining for staff on the forms, and regulation 6400.141(c)(6). 08/15/2022 Implemented
6400.151(b)The physical examination, completed 5/6/2022 for Direct Service Worker #2 was not signed and dated by the medical professional. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The staff will obtain the correct signature from the Physician who administered her physical by 8/8/2022 08/08/2022 Implemented
6400.50(a)Direct Service Worker #1's record of training for training year January 1, 2021 to December 31, 2021 does not include the source or content for trainings outlined in 6400.52c1-6.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.DSW #1 was added to the DTE Relias Training Platform on 8/1/2022. The employee has been required to complete all required training using Down to Earth's online Relias Platform. This includes the content/source needed for reference. The completed training is then verified by the CEO. 08/01/2022 Implemented
6400.166(a)(11)Individual #1's July 2022 Medication Administration Record did not include a purpose or diagnosis for all medications being prescribed.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.Individual #1's MARs have been corrected by his Direct Support Professionals on 07/27/22 to include the purpose or diagnosis for every medication prescribed. 08/05/2022 Implemented
SIN-00191288 Renewal 07/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(2)Individual #1's most recent ISP, last updated on 7/8/21, states, "Leo is able to tempter his water independently although he will not clean himself without partial physical assistance." Individual #1's assessment completed on 4/9/21, states he may need hand-over-hand or verbal prompts to temp his own water.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.A letter was sent to the supports coordinator via email to make the necessary corrections to individual #1's ISP in order for it to match the assessment. The supports coordinator responded with confirmation email of the change. 08/16/2021 Implemented
SIN-00244940 Renewal 06/25/2024 Compliant - Finalized