Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00284288 Renewal 12/05/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(a)Individual #1 monthly SSI income is $1601.30, monthly room and board charges $1152.94 which exceeds the maximum rate $712.15 in ODP announcement 00-25-01There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. The Director admitted the error at the time of inspection and reimbursed the individual with the excess money he paid for Room & Board from March 2025 -- November 2025. The incident was reported in the EIM system as, "Financial Exploitation (Room & Board). 12/05/2025 Implemented
6400.62(a)Extra home fragrance bottles were found in the kitchen island drawer as well as hand soaps and sanitizers in the bathrooms with labels with instructions for poison control if ingested. The ISP for the individual who solely lives at the home requires for safety precaution that "these items are out of ··· reach at home".Poisonous materials shall be kept locked or made inaccessible to individuals. The House Manager removed the fragrance bottles from the drawer and kept them in a locked cabinet, which is not accessible to the individual. The Hand soap and sanitizer found in the bathroom were also removed by the House Manager and stored in a locked cabinet and the key kept out of reach of the individual 12/05/2025 Implemented
6400.64(b)Evidence of insects/rodents was observed in two instances. Rodent droppings were observed in the cabinet below the kitchen island. Also, a dead fly was observed in the corner cabinet of the kitchen where rice was stored.There may not be evidence of infestation of insects or rodents in the home. : The droppings were cleaned with disinfectant and the dead fly removed from the cabinet by a support staff. Staff disposed of the rice and cleaned the cabinet thoroughly with soap. The House Manager submitted a Maintenance/Repair Request (Appendix C1) to the Director for immediate action. A contract was awarded to "Nothing to Something LLC" to treat the infestation, which he completed on 12/6/25 (Appendix C2). 12/06/2025 Implemented
6400.67(b)The dryer's lint trap was filled. This was corrected while the inspector was on-site. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint was removed and the lint trap cleaned by the House Supervisor during the inspection. Staff cleaned the floor and made sure it was free from any hazard. 12/05/2025 Implemented
6400.151(a)Staff #1 -DSP- date of hire 7/2/2024. Employee Physical in the record is dated 1/31/2025 - employees shall have a physical examination within 12 months prior to employment and every 2 years thereafter 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. : Upon being aware of the violation, the staff was taken off the schedule and asked to complete her physical before returning to work. She completed the physical on 1/31/25. 12/08/2025 Implemented
6400.166(a)(11)The Medication Administration Record (MAR) did not note the diagnosis or purpose for the medication's issuance. It is noteworthy that the provider had the medication fact sheet in the medication binder although instructions did not specifically state why the individual was prescribed the 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 MAR has been updated to include the purpose of the medication. (Appendix A). 12/05/2025 Implemented
SIN-00259720 Renewal 02/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff members 2, 3, 5, and 6 were hired on 07/01/24 and the criminal history background check was not requested until 01/28/25.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. The criminal background check for all staff members has been completed. 02/07/2025 Implemented
6400.21(b)There is no attestation of PA residency for the past two years and there is no FBI criminal history record check for staff member 1.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. Staff member 1 has signed the attestation of PA residency and submitted a copy of her driver¿s license and FBI criminal history check as proof of residence. 02/07/2025 Implemented
6400.104The provider did not provide a notification to the fire department.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Notification letter has been sent to the local fire department (Philadelphia Fire Department) in Woodland, PA. A copy of the letter is attached 02/04/2025 Implemented
6400.151(a)There is no physical examination in file for Staff members 2 and 3. 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. The general physical examination for staff members 2 and 3 has been completed. The results are attached 02/13/2025 Implemented
6400.18(i)Individual 1 - There is an open incident which occurred on 9/9/2024 for choking, he was taken to the ER, no follow up details yet, no extension requested.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The point person has requested an extension to enable him to gather all the relevant information to finalize the incident. 02/12/2025 Implemented
6400.32(r)Individual 1 - The Individual rights on file do not include the right to lock the individual's bedroom door.An individual has the right to lock the individual's bedroom door.The individual has been informed of his rights, including the right to lock his door. He has initialed them accordingly. A copy is attached 02/07/2025 Implemented
6400.46(a)Staff member 4 was hired on 07/01/24 and did not have the fire safety training until 10/03/24.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.All staff have received training in fire safety by a fire safety expert 02/07/2025 Implemented
6400.52(c)(4)Staff member 1 did not complete the Recognizing and reporting incidents annual training.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff member 1 has completed the training. Training record is attached 02/12/2025 Implemented
6400.52(c)(6)Staff member 1 did not complete the Implementation of the individual plan annual training.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff member 1 has completed the training. Training record is attached 02/12/2025 Implemented