Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290761 Technical Assistance 06/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The fire department notification dated January 2, 2026, for the residence was sent to the Elkins Park Fire Company, which is neither the appropriate responding entity nor the closest one. The agency's Emergency Plan--- listed the Norristown Fire Department, 235 Airy Street, Norristown, PA.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. The LIFE Group completed an immediate review of the annual Fire Department Notification process for all applicable residential locations. Corrected Fire Department Notification letters were prepared and reissued to the appropriate local fire departments serving each licensed home. Copies of all revised letters were retained, along with proof of mailing for each location. The corrected notification letters were printed on July 1, 2026 and mailed on July 6, 2026 by Executive Oversight. 07/06/2026 Implemented
6400.151(a)The only physical on file for Staff Person #1 is dated 3/23/2022. Physicals should have been completed in March 2024 and March 2026 at minimum. 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. Staff member 1 submitted a physical examination on July 1, 2026, dated April 21, 2025, which had previously been submitted to another employer (see attached completed physical exam). The employee's physical file is now current. In addition, at the all staff meeting on July 20, 2026 the updated DSP job description will be reviewed with all employees and then an electronic copy will be sent and required to sign the updated job descriptions acknowledging that physical examinations are due every two years in accordance with regulatory requirements (see attached signed job descriptions). Employees were also informed that TB testing is not required every two years if the most recent TB test was negative; however, if an employee has a history of a positive TB test, follow-up documentation and monitoring must be maintained in accordance with medical guidance and agency requirements. Staff were further notified that failure to submit a required physical examination on or before the expiration of the most recent physical on file may result in suspension from work and possible termination. The Administrative Assistant was retrained on the process for tracking, monitoring, and following up on all employee documents with expiration dates, including physical examinations and related health documentation on July 08, 2026. 07/20/2026 Implemented
SIN-00260477 Unannounced Monitoring 02/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)A review of the Medication / MAR was done for individual #1. On 2.12.2025 the count was correct showing that all prescribed 8am meds were administered. The mar was blank for 2/12/2025.showing no initials or documentation, to validate who administered the medication.A 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.The organization ensures that the name and initials of the person administering medications is recoded after each administration. The staff who administered the medication was identified and returned to the site to complete the documentation and retrained on the importance of documenting after each med administration. 02/12/2025 Implemented
SIN-00253872 Unannounced Monitoring 10/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were poisons found unlocked in the upstairs bathroom of the home. A spray bottle of Clorox Cleanup was laying out in plain sight in the bathroom and other cleaning products were in an unlocked cabinet. Both the ISP and the annual assessment for the individual living in the home state that poisons are required to be locked. Staff working in the home on the date of the inspection told the licensing representative that the individual living in the home was unable to navigate the steps. However, the ISP states that the individual can navigate uneven terrain and stairs with minimal difficulty.Poisonous materials shall be kept locked or made inaccessible to individuals. The LIFE GROUP will ensure that poisonous materials are locked and made inaccessible to the individuals. The poisons from upstairs were removed and locked in the cabinet with the other poisons in the office. Staff will be retrained this month on the safety section of the ISP as it relates to poisons. 10/17/2024 Implemented
6400.64(a)There was significant grease and dirt buildup inside the oven door and on the bottom of the oven that requires cleaningClean and sanitary conditions shall be maintained in the home. The LIFEGROUP will ensure clean and sanitary conditions will be maintained throughout the home. The oven was cleaned inside and out to remove the grease and dirt buildup that was noted by the auditor. 11/01/2024 Implemented
6400.72(b)The back door leading from the kitchen to the outside of the home has a screen door where the screen is torn at the bottom and requires repair or replacement. Repeat violation Screens, windows and doors shall be in good repair. The LIFEGROUP shall ensure that screens, windows, and doors shall be in good condition and repair. The storm door was replaced with a new fully functioning door. 11/01/2024 Implemented
6400.112(a)The ISP and annual assessment for Individual #1 both state that the individual benefits from warnings prior to the fire alarm sounding in the home. While completing the unannounced inspection, the staff at the home indicated that it would be problematic if the individual would be asked to leave the home when testing the alarm. A review of the past year of completed fire drill forms did not indicate either prior warning before the drills nor did they indicate that there were problems during the drills, including during the sleep-time drills, where only one staff was present. Based on the information in the assessment and the ISP, and the interview with staff on the date of the unannounced inspection, the fire drills being completed in the home are not unannounced as required by regulation and are not an accurate reflection of the time necessary to evacuate the residence. Repeat Violation. An unannounced fire drill shall be held at least once a month. The LIFE GROUP will ensure that unannounced fire drills will be held once monthly. The November fire drill was an unannounced drill that was conducted by the Program Manager. 11/08/2024 Implemented
6400.144Individual #1 is prescribed SF 5000 Plus prescription toothpaste. The prescription label states to apply to teeth when brushing teeth twice daily for dental care. It is also written in the narrative space on the MAR exactly the same way. However, it is listed on the MAR as a PRN and staff are only initialing once daily that the prescription toothpaste is being administered for toothbrushing. In addition, no initials at all were on the MAR for administering the prescription toothpaste on 10/11/24 or 10/14/24. Repeat ViolationHealth services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The LIFE GROUP shall ensure that all health services, medical, pharmaceutical, dental, dietary, and psychological are planned for and provided. The correction involved having the pharmacy correcting the MAR to include it as a scheduled med instead of a PRN medication. 11/01/2024 Implemented
6400.181(f)The annual assessment for individual #1 was written and copied to the individual's team on 7/1/24. The ISP meeting for the individual was held on 7/18/24. This does not meet the regulation which requires the program specialist to provide the assessment to the team at least 30 days prior to the ISP meeting. Repeat ViolationThe program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The LIFE GROUP shall ensure the PS provides the annual assessment to the team members 30-dayss prior to the ISP meeting. The newly appointed PS has created a document to indicate when the annual assessments are due. to ensure the assessments are sent to the team 30 days before the ISP meeting timeframe. 11/04/2024 Implemented
SIN-00239010 Renewal 01/29/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was an unlocked container of Bleach under the sink in the ground floor bathroom of the home.Poisonous materials shall be kept locked or made inaccessible to individuals. The LIFE Group will ensure that poisonous materials will be kept locked or made inaccessible to the individuals if dictated in the ISP. Staff members were retrained on keeping poisons locked per the individual's ISP. 02/20/2024 Not Implemented
6400.68(b)Water Temperature in the bathroom in the home was 127.5 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The LIFE Group will ensure the hot water temperature bathtubs and showers may not exceed 120 degrees Fahrenheit. The water temperature was adjusted. 01/29/2024 Not Implemented
6400.112(c)Fire drill conducted 10/9/23 does not include the time of the drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The LIFE GROUP will ensure that written fire drills contain all pertinent information as per 6400 regulations. 02/07/2024 Not Implemented
6400.112(e)There were no sleep drills conducted from 6/2023-12/2023.A fire drill shall be held during sleeping hours at least every 6 months. The LIFEGROUP will ensure that an overnight fire drilled will be conducted every 6 months to remain in compliance with the 6400 regulations. An overnight fire drill was conducted. 02/12/2024 Not Implemented
SIN-00205653 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)There was no first aid manual in the first aid kit. A first aid manual shall be kept with the first aid kit.A first aid kit was placed in the home. 09/08/2022 Implemented
6400.82(f)No paper/cloth towels found in 2nd floor bathroom-replaced during inspection.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. paper towel was placed in the bathroom during inspection 05/24/2022 Implemented
6400.110(b)No operable smoke detector located within 15 feet of individual 2's bedroom.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. an operable smoke detector was on site during the inspection, but inspector overlooked it as it was at the begining of the entrance of the individual's bedroom. A picture of the smoke detector was sent the same week after the inspection. 05/24/2022 Implemented
SIN-00266466 Unannounced Monitoring 05/19/2025 Compliant - Finalized