Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261706 Unannounced Monitoring 01/30/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 1/30/2025 the following dirty and unsanitary conditions were observed: The toaster oven in the kitchen was covered in a black substance resulting from overcooked food, the glass door to the toaster over was covered in brown food splatter, the 2-slice bread toaster was dirty and covered in food crumbs, and Individual #1's bedroom contained a miniature refrigerator, with a dried coating of milk and another brown substance on the bottom shelf.Clean and sanitary conditions shall be maintained in the home. 1. Immediate Cleaning: A thorough cleaning of all kitchen appliances, including the toaster oven, bread toaster, and the miniature refrigerator in Individual 1's bedroom, has been conducted to remove all food residues and splatters. 2. Replacement: The toaster oven has been replaced, effectively eliminating the source of contamination and ensuring hygiene. 3. Staff Re-Education: A training session has been organized for all staff members, emphasizing the importance of maintaining clean and sanitary kitchen environments. This training covered: - Proper cleaning protocols for kitchen appliances after each use. - Guidelines for identifying and reporting worn or damaged appliances. 4. A daily cleaning checklist for kitchen appliances has been implemented, ensuring regular inspections and cleaning. 03/12/2025 Not Implemented
6400.77(b)On 1/30/2025 the first aid kit did not contain a thermometer. 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. 1. Immediate Addition: A digital thermometer has been added to the first aid kit, ensuring compliance with required supplies. 2. Staff Retraining: All staff have undergone retraining on the updated first aid kit inspection procedure, including: - Proper use of the digital thermometer. - Importance of maintaining a fully stocked first aid kit. 3. Daily Checklist: A daily checklist has been implemented for staff to verify the presence of all necessary first aid supplies. 4. Notification Protocol: A clear protocol for notifying supervisors if any item is removed from the first aid kit has been established. 03/12/2025 Implemented
6400.171On 1/30/2025 the second-floor vacant bedroom contained a miniature refrigerator, which contained a 7.2 fl/oz. can of prune juice, which expired in December 2023.Food shall be protected from contamination while being stored, prepared, transported and served. 1. Immediate Inspection: An immediate inspection of all refrigerators and freezers has been conducted, identifying and removing any expired food items. 2. Thorough Cleaning: All refrigerators and freezers have been cleaned to ensure a hygienic storage environment. 3. Staff Training: Training sessions focusing on food safety practices have been provided to all staff. 03/12/2025 Not Implemented
6400.165(b)Individual #2 is prescribed Lorazepam .5mg with instructions to "Take 1 tablet by mouth three times a day for anxiety". On 1/30/2025 Individual #2 had Lorazepam .5mg., which contained a sticker over the label issued by the pharmacy stating "Directions changed refer to chart".A prescription order shall be kept current.1. Immediate Review of Prescription: A thorough review of Individual 2¿s current prescription for Lorazepam has been conducted to confirm any changes. 2. Consultation with Pharmacy: The pharmacy has been contacted to clarify changes and obtain updated prescription details. 3. Update Medication Administration Records: Medication administration records have been updated to reflect current prescription instructions. 4. Notify Relevant Staff: All staff members involved in the medication administration for Individual 2 have been informed of the updated directions. 03/12/2025 Implemented
6400.166(a)(9)Individual #2 is prescribed Lorazepam .5mg with instructions to "Take1 tablet by mouth three times a day for anxiety". On 1/30/2025 Individual #2's January 2025 medication administration record documented Lorazepam .5mg, "Take 1 tablet by mouth two times a day for anxiety".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.1. Immediate Reconciliation: The correct dosage and administration schedule for Individual 2 have been clarified. 2. Update Medication Administration Record: The Medication Administration Record (MAR) has been revised to accurately reflect the current dosage and frequency. 3. Count Sheet Correction: An updated count sheet from the pharmacy has been requested to align with the revised MAR. 4. Staff Notification: All relevant staff members have been informed of the changes. 03/12/2025 Not Implemented
SIN-00253709 Renewal 10/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's physical examination, completed 2/19/2024 did not include a review of past medical history.The physical examination shall include: A review of previous medical history. Residential supervisors addressed the missing documentation in the physical examination by coordinating with healthcare providers to gather the necessary information. Once retrieved, they attached the missing documentation to the physical examination form. 10/25/2024 Implemented
6400.181(e)(1)Individual #1's assessment, completed 5/2/2024 did not include functional strengths, needs, preferences of the individual. This section was left blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The program specialist took the initiative to review all skills assessments for any incomplete sections. After identifying the missing information in Individuals assessment, she quickly filled in the blank with detailed insights about the individual's strengths, needs, and preferences. Once this important information was updated, the program specialist informed the treatment team of the changes. 10/25/2024 Implemented
6400.181(e)(10)Individual #1's assessment, completed 5/2/2024 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The program specialist reviewed all skills assessments for any incomplete sections. Upon discovering the missing lifetime medical history, she used the new form to document this essential information within the assessment. After updating the details, the program specialist quickly informed the treatment team of the changes. 10/25/2024 Implemented
6400.181(e)(12)Individual #1's assessment, completed 5/2/2024 did not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The program specialist proactively reviewed all skills assessments for any incomplete areas. Upon discovering that recommendations for specific training, programming, and services were missing, she completed all relevant sections of the assessment. After updating the necessary details, the program specialist promptly informed the treatment team of the changes. 10/25/2024 Implemented
SIN-00233740 Renewal 10/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.107At 1:51PM on 11/1/2023, a portable space heater was in the supply closet in the basement of the home. [Repeat Violation, 3/29/2023]Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. 1. The portable space heater was removed from the Benwood residential on 11/1/2023 at 1:55PM. 2. On 11/6/23, all residential supervisors and program specialist were trained on the dangers of space heaters. 3. On 11/6/23, all residential supervisors and program specialist were trained on the mandated restrictions of portable space heaters in any room, including staff rooms. Hello, the violation 55 PA Code Chapter 6400.107 is correct and was founded on 11/1/2023. It is not a repeat violation, 3/29/2023. This violation has not occurred at the Benwood house or any other TFS locations before 11/1/2023. 11/12/2023 Implemented
SIN-00221737 Renewal 03/28/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1, date of admission 2/11/2021, had an initial Tuberculin testing completed on 3/12/2022.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. TFS supervisors are working together to document and track important client dates on a spreadsheet for client medical and mental health appointments. 04/24/2023 Implemented
6400.141(c)(14)Individual #1's physical examination, completed on 1/24/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Staff will be retrained on the physical examination form understanding that all information is required to be filled out by medical personnel including medical information pertinent to diagnosis and treatment in case of an emergency . Documentation will be on record. [Individual #1 had a physical examination completed 4/10/2023 to include medical information pertinent to diagnosis and treatment in case of an emergency. (AES,HSLS on 5/1/2023)] 04/24/2023 Implemented
6400.34(a)Individual #1 was informed and explained her Individual Rights on 1/1/2023. These rights did not include 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. Individual #2 was informed and explained his Individual Rights on 1/1/2023. These rights did not include 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The TFS Rights review and client signature sheets were updated to include: 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. 04/24/2023 Implemented
6400.165(g)Individual #1 had a psychiatric medication review on 5/3/2022 and then again on 3/21/2023. These psychiatric medication reviews did not include the medications or the need to continue the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The TFS psychotropic medication review form was updated to include detailed information to include the medications and/or the need to continue the medications. Documentation of the revised form will be provided. 04/24/2023 Not Implemented
6400.169(b)(2)Individual #1 is prescribed Tresiba FlexTouch for Diabetes. The agency staff have administered and documented administering this medication from 3/1/2023 to 3/10/2023 and from 3/12/2023 to 3/23/2023. The agency staff have not completed a Department approved diabetes patient education training program.A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months.TFS staff have enrolled and have taken a Department-approved diabetes patient education program through Penn State Beaver on 4/4/23. Documentation of enrollment can be provided. TFS are still waiting for certificates via email. 04/24/2023 Implemented
6400.213(1)(i)Individual #1's record does not include identifying marks. This section was left blank. Individual #2's record does not include identifying marks. This section was left blank.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.TFS supervisors will be retrained on completing the Individual's face sheet including identifying information such as personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. 04/24/2023 Implemented
SIN-00203761 Renewal 04/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The 7 wooden steps leading from the 2nd floor exit to the outisde did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Nonskid surfaces were put on the 7 wooden steps leading from the 2nd floor exit to the outside. This was done to reduce the risk of falling when ascending or descending stairs. [Picture showing non-skid installed on stairs received on 5/18/22 and reviewed 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 05/06/2022 Implemented
6400.111(a)The fire extinguishers located in the basement, on the 1st floor in the kitchen, on the 2nd floor in the hallway, and in the 3rd floor hallway of the home had a 1A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Fire extinguishers were replaced with a minimum 2-A rating. The violation was fully corrected. [Receipt for purchase of 4 fire extinguishers, dated 5/4/22, received 5/18/22 and reviewed on 5/20/22. Five pictures of fire extinguishers placed in home received 5/18/22 and reviewed on 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 05/06/2022 Implemented
SIN-00188398 Renewal 04/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Program Specialist #1's physical examination completed 8/10/20, Direct Service Worker #2's physical examination completed 11/19/20, Direct Service Worker #3's physical examination completed 6/3/20, Direct Service Worker #4's physical examination completed 1/7/21 and Direct Service Worker #5's physical completed 1/6/21 do not include a signed statement that the staff person is free of communicable diseasesThe physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the dease to individuals.Tucker Family Supports (TFS) updated the staff and consumer physical form to properly document immunizations as well as communicable diseases and included specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. 05/05/2021 Implemented