Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256414 Renewal 11/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror in the individual's bedroom. A review of the individual's BSP did not include restriction around mirrors in the bedroom.In bedrooms, each individual shall have the following: A mirror. Maintenance will install mirror in individual 1 room 12/01/2024 Implemented
6400.104The fire department notice did not include specific information about the location of the individual's bedroom.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 Director of Operations will amend the fire department notice to include the location(s) of the individuals bedrooms 12/01/2024 Implemented
6400.106The provided furnace documentation were proposals for service only and not invoices or receipts for completed work.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. Director of Operations will obtain written documentation of professional furnace cleaning 12/01/2024 Implemented
6400.112(f)There were no alternate routes used for fire drills the entire year. The record review indicated that the front door was used for the exit for the entire past year.Alternate exit routes shall be used during fire drills. House Manager will conduct monthly fire drills as required using alternate routes when exiting. 12/01/2024 Implemented
6400.52(c)(1)Staff 6 did not complete the training during the 2023 training period.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.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
6400.52(c)(2)Staff 6 did not complete the training during the 2023 training period.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.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
6400.52(c)(3)Staff 6 did not complete the training during the 2023 training period.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
6400.52(c)(4)Staff 6 did not complete the training during the 2023 training period.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
6400.52(c)(5)Staff 6 did not complete the training during the 2023 training period.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
6400.52(c)(6)Staff 6 did not complete the training during the 2023 training period.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.Coordinator of training and Compliance will revise the training approach of the organization to include certificate of completion from a recognized training source for the required initial and annual training 12/01/2024 Implemented
SIN-00235281 Renewal 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Living room bay window broken, covered with plastic: says it is being reordered. Individual broke it. Floors, walls, ceilings and other surfaces shall be free of hazards.Bay Window was repaired on 1/15/24. 01/15/2024 Implemented
6400.72(a)In the empty bedroom, a screen is missing on the window.Windows, including windows in doors, shall be securely screened when windows or doors are open. Window is broken and needs to be repaired. Upon repair screen will placed in window. A request has been placed with landlord to assess window and repair 02/28/2024 Implemented
6400.81(k)(6)There is no mirror in Individual 1's bedroom.In bedrooms, each individual shall have the following: A mirror. Maintenance Team placed a mirror in individual 1 bedroom. 01/16/2024 Implemented
6400.111(a)The attic does not have a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Maintenance team installed a fire extinguisher in the attic. 12/01/2023 Implemented
6400.141(c)(6)Individual 1's TB testing was not received.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. A prescription was requested on 1 24.23 for a TB test to be administered to individual . Upon receipt of prescription house manager and or staff will take him to get the TB test 01/24/2024 Implemented
6400.141(c)(7)Individual 1's GYN exam was due in November, the last exam was completed on 11/14/22.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Delay was caused by changing counties and insurance. Program Specialist applied for new insurance. Upon receipt of insurance card an appointment will be scheduled 02/28/2024 Implemented
6400.181(e)(12)The recommendations are not addressed in Individual 1's annual assessment for services, training, and programming. It references going out to play basketball and the YMCA.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Specialist revised assessment to include recommendations for specific areas of training, programming and services. 01/01/2024 Implemented
6400.32(r)Individual 1's individual rights form does not address that an individual has the right to lock their bedroom door.An individual has the right to lock the individual's bedroom door.Director of Operations amended individual Rights Policy was amended to include the right to lock their bedroom door. 01/01/2024 Implemented
6400.166(b)Staff Signed Individual 1's mar on 11/30 for metformin 500 mg for pm dosage in error. Medication was still in corresponding blister pack.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff were educated on appropriate storage and allocation of medication. Procedure implemented to assure staff are using respective and appropriate pack at the designated time when medication is given multiple times a day. 12/01/2023 Implemented
6400.213(1)(i)Individual 1's record does not list identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Director fo Health Services amended face sheet for individual 1to include all identifying marks. 01/24/2024 Implemented