Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231981 Renewal 09/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The fence rail is loose on the left side of the wheelchair ramp entrance.Floors, walls, ceilings and other surfaces shall be in good repair. The railing is secured with 4 L brackets, and it was secured with the 4 L brackets that a tight. Attachment 3 photo of the ramp with the brackets. This was not mentioned during the exit interview but when the executive director saw this they immediately check the ramp and it was secured. 11/02/2023 Implemented
SIN-00213227 Renewal 09/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)The criminal history background check for staff 1 was completed on 6/2/22, which is more than five days after her hire date of 5/26/22.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. New hire direct care staff did apply for the out of state clearance on 5/26/2022, which was received 6/2/2022. Document 11 01/15/2023 Implemented
6400.66There was no light bulb in the fixture at the front door.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb was replaced 9/28/22, as fate would have it the bulb went out that morning we forgot to replace it before the inspector arrived, but it was replaced within 24 hours. 09/28/2022 Implemented
6400.110(g)The smoke detector for the interconnected system was not functional throughout the house when a test was attempted. *documented contact to the protection agency regarding this issue was submitted prior to the close of business post the exit meeting. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. The smoke detector system was operative however the drill button did not work on the keypad. The monitoring system noted that there was still fire protection. 10/27/2022 Implemented
SIN-00193628 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Several tiles appeared to have come loose from the tiled floor surrounding the sump pump in the basement laundry room, exposing the concrete floor underneath. These tiles were seen pushed against a nearby wall.Floors, walls, ceilings and other surfaces shall be in good repair. The lose tiles were removed with no plans to have them replaced, as it is not a needed item in the basement. the basement was flooded during the storm Ida which flooded the Phoenixville area. 09/30/2021 Implemented
6400.82(f)There was no wall mirror located in the basement bathroom.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. A mirror was placed in the basement staff bathroom. see attachment #2 09/30/2021 Implemented
6400.82(g)There were no toothbrushes available within the home for Individual 1, Individual 2, or Individual 3. Staff on site noted that all three of these individuals could not have their teeth brushed with toothbrushes and toothpaste due to medical concerns related to choking risk; instead, staff use pre-packaged "brushettes" made for this purpose. At the time of inspection, no documentation was made available to show that these individuals should not have their teeth brushed using a traditional toothbrush and toothpaste. As such, a toothbrush should be maintained for each individual within the home so that one is available for each of them upon demand. An individual washcloth, bath towel and toothbrush shall be provided for each individual.Individual #3 toothbrush was placed in the bathroom, see attachment #3 Individual #1 dentist says brush with the toothettes, see attachment #4 Individual #2 does not have teeth. See attachment #5 Nurse is responsible 09/30/2021 Implemented
6400.163(a)Individual 1's September 2021 Medication Administration Record (MAR) documents that the individual was prescribed "Colace 2-in-1" and "CB-1" by their physicians. Neither of these medications had a pharmacy label affixed to their packaging.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The prescriptions for both Colace 2 in 1 and the CB1 were provided to the pharmacy where they were packaged with a pharmacy label. see Attachment 7 and 8 10/01/2021 Implemented
SIN-00149524 Renewal 01/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not include a thermometer, however, it was replaced during inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The thermometer fell out of the first aid roll as the CEO was taking it to the licensing inspector. The thermometer was immediately handed to the licensing inspector. When carrying the first aid kit CEO will make sure it's closed. 02/01/2019 Implemented
6400.110(a)The smoke alarm was inoperable on the second level of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detector did sound when smoke was used to set it off, however the test button would not work. On 1/31/19 the CEO contacted the smoke detector company the technician came out on 1/31/19 noted that the test button bell was set to silence, this was reset to sound. On 2/1/19 another technician from the alarm company performed a test on the entire fire system, there were no issues. We now know about the test sound button, and will check the position of the button to make sure it's in the sound position if testing doesn't produce a sound. This test sound button does not affect the fire system from working in an actual fire. 02/01/2019 Implemented
SIN-00106084 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #2¿s financial record did not have receipts or a ledger for the months of 11/15, 12/15, 1/16 and 2/16. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. An employee was hired dedicated to filing the individual records to ensure financial records are properly filed. In the future purged files will remain accessible until reviewed by licensing inspector. 12/09/2016 Implemented
6400.151(c)(4)Staff #1¿s annual physical exam, dated 1/3/0/16, listed incorrectly that medical problems existed and no further information was provided. The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.The employee physical was corrected. In the future in hopes of avoiding a non compliance the physicals will be reviewed for mistakes and omissions prior to filing, and returned to physician for correction if needed. 12/13/2016 Implemented
6400.181(c)Individual #2¿s annual assessment dated 6/05/16 does not indicate what instruments the assessment were based on. The assessment shall be based on assessment instruments, interviews, progress notes and observations. The statement that the assessment was based on assessment instruments, interviews, progress notes and observations was placed with the assessment. What the assessment was based on will be attached to the assessment in the future to avoid a non compliance. 12/06/2016 Implemented
6400.181(e)(5)Individual #2¿s annual assessment dated 6/05/16 did not indicate the individual¿s ability to self-medicate. The assessment must include the following information:  The individual's ability to self-administer medications.The ability to self medicate was listed under Medication administration in the lifetime medical, however it was added to the annual assessment section. To avoid a non compliance in the future the ability to self medicate will be with the annual assessment. 12/09/2016 Implemented
6400.181(e)(13)(ii)Individual #2¿s annual assessment dated 6/05/16 did not indicate progress and growth in the area of motor and communication. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The heading Motor and progress and growth information was added to the assessment, also progress and growth information was included under communication skills. To avoid future non compliance headings of Motor and Progress and growth were added to the assessment to be completed. 12/09/2016 Implemented
6400.181(e)(14)Individual #2¿s annual assessment dated 6/05/16 did not indicate the individual¿s ability to swim. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. This individual's assessment has "he does not swim" To avoid a future non compliance a sentence was added he does not have the ability to swim. 12/09/2016 Implemented
SIN-00253199 Renewal 09/25/2024 Compliant - Finalized
SIN-00176916 Renewal 09/24/2020 Compliant - Finalized
SIN-00124620 Renewal 10/24/2017 Compliant - Finalized
SIN-00048163 Renewal 03/26/2013 Compliant - Finalized