Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279677 Unannounced Monitoring 12/05/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Two (2) one-quart cans of high gloss paint were found in the kitchen cabinets. Both cans were relocated to a locked closet at the time of inspection. Individual #1's ISP states, "It is unknown if (they) would digest poisonous substances in the event of (them) having suicidal ideations. Poisonous materials are kept locked per regulations."Poisonous materials shall be kept locked or made inaccessible to individuals. - Immediate corrective action: All paint and other hazardous/poisonous materials were removed from kitchen cabinets and secured in a locked closet during the inspection. - System fix: A full-house environmental sweep was completed to confirm all chemicals, paints, and similar materials are locked/inaccessible (including maintenance closets, laundry, bathrooms, and under-sink areas). - Staff instruction: Staff on duty were immediately coached on acceptable storage locations and the requirement to keep poisonous materials locked at all times. 12/31/2025 Implemented
6400.68(b)The hot water in the kitchen sink measured at 124.9°, and the hot water in the bathroom measured 126°; both of which exceed the 120° maximum and 2-degree variance outlined in the RCG. Hot water temperatures in bathtubs and showers may not exceed 120°F. - Immediate corrective action: Maintenance request was made to adjust hot water heater/mixing valve settings to reduce hot water output; staff were instructed to monitor for scald risk until verification was complete. - Verification: Water temperatures were re-checked using a calibrated thermometer at the bathroom tub/shower and sinks to confirm temperatures at or below 120°F. - Repairs (if needed): If temperatures could not be stabilized through adjustment a request will be made to repair the valve for the hot water heater. 12/31/2025 Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not posted on or near the office telephone. Emergency numbers were posted on the living room wall by the front window; however, a telephone was not located in the living room, dining room, or kitchen areas.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. - Immediate corrective action: Laminated emergency number sheets (hospital, police, fire, ambulance, poison control) were posted directly next to the office telephone with an outside line. - Access improvement: A telephone with an outside line was placed in a common area (kitchen/dining) or emergency numbers were posted next to any additional outside-line telephones used by staff. 12/22/2025 Implemented
6400.72(a)No screen was found in the office window located to the right of the office desk. The window is able to be opened No screens were found in the living room window closest to the front door. The windows are able to be opened.Windows, including windows in doors, shall be securely screened when windows or doors are open. - Immediate corrective action: The affected windows were kept closed and/or restricted from opening until screens were installed. - Repair: Replacement screens were measured and ordered; once received, maintenance installed secure-fitting screens on the identified office and living room windows. 12/31/2025 Implemented
6400.81(k)(6)Individual #1's bedroom was not equipped with a mirror. The ISP does not indicate an exception to the regulatory requirement.In bedrooms, each individual shall have the following: A mirror. - Immediate corrective action: Individual restriction plan includes removal of breakable objects from their room due to suicidal ideations. - Documentation: A copy of the restriction plan has been placed in apartment. - Staff guidance: Staff were reminded that required bedroom furnishings must be in place unless an ISP documents a specific exception. 12/22/2025 Implemented
6400.144Individual #1 is prescribed Norethindron Tab 0.35% Oral Contraceptive (take 1 tablet by mouth daily at 8:00 am). This medication was listed on the December 2025 MAR; however, was not available in the home. Individual #1 was prescribed Ofloxacin 0.3% Op Solution (instill 10 drops to the right ear daily at 8am for infection for 7 days). The medication was dispensed 11/19/25 as a time-limited medication, and no longer appears on the MAR. Per staff, the medication is not being offered; however, there is no discontinuation order on file, and no documentation was available to support that the infection was resolved.Health 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. - Immediate corrective action: Medication reconciliation was completed with the pharmacy and prescriber(s). Any active medications missing from the home were obtained the same day via pharmacy delivery or pickup. - Prescriber documentation: The prescriber was contacted to obtain written clarification: (a) whether the Ofloxacin course was completed and should be discontinued, and (b) whether follow-up was required to confirm infection resolution. Written orders/notes were filed in the individual's record. - MAR correction: The MAR was updated to match current prescriber orders and pharmacy profile. Any discontinued/time-limited medications were clearly documented with start/stop dates and discontinuation orders. - Nursing oversight: The agency RN completed a targeted medication management review and provided staff coaching on medication reconciliation, time-limited medications, and required documentation. 12/29/2025 Implemented
6400.18(a)(5)Incident 9742562 for Individual #1 was created on 12/3/2025. The discovery date was 11/26/2025.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. - Immediate corrective action: The incident was reviewed by the Program Specialist/Program Manager and Administrative staff to confirm event details and ensure the report includes complete, accurate information, including the correct discovery date and narrative context. - Root cause analysis: Management identified a gap in staff understanding of what constitutes 'discovery' and the escalation steps for time-sensitive reportable incidents. - Training and accountability: All direct support professionals and site leadership were re-trained on 6400 incident reporting timelines and 'discovery' definition, with emphasis on neglect reporting within 24 hours. Competency is documented via sign-in and post-training knowledge check. Coaching/disciplinary action will occur when late reporting is confirmed. 12/29/2025 Implemented
6400.165(c)For Individual #1, the following medication was found in the home; however, was not listed on the MAR: Lo-Zumandimi 3-0 .02mg oral contraceptive tablet (take by mouth daily at 8am).A prescription medication shall be administered as prescribed.- Immediate corrective action: Medication reconciliation was completed to determine whether the medication is an active order. Staff were instructed not to administer any medication not present on the MAR until the MAR was corrected/confirmed by the prescriber/pharmacy record. - MAR update or removal: If active, the medication was added to the MAR with correct dose/time and verified against the prescription label and/or pharmacy profile. If not active, the medication was removed from use and disposed/returned per pharmacy guidance and provider policy, with documentation of removal. - Staff coaching: Staff were re-trained that the MAR must match current orders, and medications in the home must be reconciled immediately when new medications arrive or when the MAR changes. 12/29/2025 Implemented
6400.165(e)Individual #1 is regularly refusing medications. A medication review was completed on 12/05/25 at 9:25 am. At the time of the review, 8:00 am medications had not been administered, and a medication refusal was not noted. In speaking with the three (3) staff present, 8:00 am medications are offered to Individual FC beginning at 8:00 am, and as late as 10:00-11:00am. If Individual is compliant, morning medications are then dispensed after the allowable window of one hour before, to one hour after the prescribed time. This same practice is in place for afternoon and evening medications. Per staff, this was agreed upon by the prescribing doctors and agency Nurse during a Team Meeting; however, there is no documentation on record to support the changes to administration times (See RCG pg 101-102).Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.- Immediate corrective action: The RN/management contacted prescribers to request written orders for any needed administration time changes (for example, to address frequent refusals). Once received, orders were filed and MAR updated immediately. - Refusal documentation: Staff were re-trained and required to document each offer/refusal on the MAR at the time it occurs, including reason (if offered) and follow-up actions. - Targeted competency review: Medication administration observations were completed for staff responsible for med passes, focusing on timing windows and refusal documentation. 12/29/2025 Implemented
SIN-00266957 Renewal 05/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a poisonous hand sanitizer in the kitchen that was locked up during the inspection. The closet where the poisons substances are held was not locked. The closet was locked during the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. The storage closet containing poisonous hand sanitizer was immediately secured with a lock at the time of inspection. All other chemical storage areas were audited to ensure they remain locked and inaccessible. 06/25/2025 Implemented
6400.68(b)Water temperature for bathtub got up to 123°F Hot water temperatures in bathtubs and showers may not exceed 120°F. The water heater thermostat was immediately adjusted to ensure the maximum temperature does not exceed 120°F. Maintenance staff verified the adjustment using a calibrated thermometer. A follow-up check was performed to confirm that all bathtubs and showers temperatures were within the acceptable range. 06/25/2025 Implemented
6400.104For Individual #2: A letter to the Fire Department is not on record. The letter provided was sent to the Police Department which operates from a different address.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. A New fire letter was drafted and delivered to the local fire department with address, resident name, and bedroom location. A File copy was placed in the emergency binder. 06/25/2025 Implemented
6400.113(a)Individual #2 was admitted to the program on 3/1/25, and fire safety training did not occur until the day after admission on 3/2/25, and this should have occurred prior to or on the day of admission. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Individual #2 received fire training the day after admission due to staff oversight. Policy now mandates training be completed before bed assignment. Staff was retrained on same-day requirement. 06/25/2025 Implemented
6400.141(c)(6)Individual #2 record does not include record of TB screening. PA DOH Immunization records, Lifetime Medical History, current physical, and other medical records did not contain any information related to TB screening.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 TB test was conducted for Individual #2 by 6/07/2025 and documented results have been placed in their medical record. We Reviewed all resident medical records to ensure TB screening compliance. 06/25/2025 Implemented
6400.143(a)Individual #2 frequently refuses medication; however, the refusals and continued attempts to train the individual about the need for health care was not documented in the individual's record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. All medication refusals and corresponding health education attempts for Individual #2 were documented retroactively in their file. Staff were retrained on documenting refusals and health discussions. 06/25/2025 Implemented
6400.144Individual #2: Lifetime Medical History and ER paperwork refers to a scheduled 4/7/25 gynecology appointment at Women's Health and Gynecology in Darby; however, there is no record to show if this appointment was completed or if the individual refused treatment. When requested, the paperwork provided refers to a 4/17/25 appointment that was not referenced in the individual's file.Health 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. It was discovered that the individual missed the GYN appointment. Contact was made with the Women¿s Health and Gynecology office to reconfirm appointment for 07/15/2025. Updated documentation has been added to Individual #2¿s file 07/15/2025 Implemented
6400.18(a)(3)Individual #2: Incident 9628204(BH Crisis) was initiated on 5/20/25, and the initial section has not been submitted.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital. The Program Specialist submitted the initial section of Incident #9628204 (BH Crisis) for Individual #2 immediately upon notice of the oversight. Retraining was provided to all relevant staff on timely incident initiation and submission through the HCSIS system within the required 24-hour window. 06/25/2025 Implemented
6400.18(i)Individual #2: - Incident 9611852 (Physical Abuse) was due on 5/27/25 and has not been extended - Incident 9628232 (Missing Individual) was due on 5/25/25 and has not been extended - Incident 9605349 (BH Crisis) was due on 5/16/25 and has not been extended - Incident 9599739 (BH crisis; not approved by county) was due on 5/11/25 and has not been extended - Incident 9628222 (Missing Individual) was due on 5/26/25 and has not been extended 6400.113(a) Ind. Trained Individual #2 was admitted to the program on 3/1/25, and fire safetyThe 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.All listed incidents were reviewed, and formal extension requests have been submitted where applicable. Staff involved have been coached on the policy requiring submission of extension requests prior to the 30-day deadline. 06/25/2025 Implemented
6400.163(h)PRN Ibuprofen 200 mg was in with individual #2 medications but was not on the MARPrescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.PRN Ibuprofen was immediately removed and destroyed per policy. A review confirmed it was not documented on the MAR. Staff involved received retraining on proper medication documentation and disposal procedures. 06/25/2025 Implemented
6400.166(a)(11)Except for the PRN medications the diagnosis or purpose for the medication was not on the MAR for individual #2A 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 diagnosis for all medications administered to Individual #2 was updated on the MAR. The nurse reviewed all current MARs to ensure compliance. 06/25/2025 Implemented
6400.166(b)The medication Quetiapine 100 mg had a dose for 05/03/25 missing in the blister pack but was not signed off on the MAR for individual #2The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The missing signature for Quetiapine on 5/3/25 was noted, and the responsible staff member was counseled and re-educated. Medication count sheets and administration times were reviewed to confirm the dose was in fact given. 06/25/2025 Implemented
SIN-00245739 Renewal 05/31/2024 Compliant - Finalized