Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262857 Renewal 03/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)Livingroom and kitchen windows did not have screens installed.Windows, including windows in doors, shall be securely screened when windows or doors are open. The CEO has requested maintenance repairs from the landlord on 3/19/2025. The contractor has installed a new screens in the living room kitchen window. Repairs were completed on 3/24/25. Before and after photos were taken. Corrections completed 03/24/2025 Implemented
6400.52(a)(3)Staff member 1 did not complete the required hours of trainings in the 2024 training yearThe following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.All staff will complete the specified annual training hours during the training period. 04/03/2025 Implemented
6400.52(c)(1)Annual training for Staff member 1 did not cover the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.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.All staff will complete the specified annual training hours during the training period. 04/03/2025 Implemented
6400.52(c)(2)Annual training for Staff member 1 did not cover 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 Service Law (23 Pa.C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704) and applicable adult protective services regulations.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.All staff will complete the specified annual training hours during the training period. 04/03/2025 Implemented
6400.52(c)(3)Annual training for Staff member 1 did not cover individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.All staff will complete the specified annual training hours during the training period. 04/03/2025 Implemented
6400.52(c)(4)Annual training for Staff member 1 did not cover recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.All staff will complete the specified annual training hours during the training period. 04/03/2025 Implemented
6400.166(a)(13)For Individual 1, there were missing signatures on the MAR for the medication administered on the following dates: 3/18/2025 & 3/19/2025A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.On the date of inspection, the mars were incomplete due to the individual refusing meds during the administered times on the 18th and 19th. according to the individual's prescription, meds are to be administered at bedtime. The program specialist contacted the prescriber to get a time adjustment. The individual's medication times were modified on 3/23/25. All staff were made aware and trained on the changes and the Mars was updated accordingly. 03/23/2025 Implemented