Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264206 Unannounced Monitoring 04/09/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144144 The Mounjaro 2.3.mg injection medication is listed on the MAR, however not on-site at the time of the review for individual two.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. Medication was administered as prescribed in the MAR and was not due until April 12th. the medication was picked up from the pharmacy and administered as prescribed. 04/11/2025 Implemented
6400.166aThere was no prescribing physician's name listed on MAR for individual one: Trazadone HCL 50 mg 1 tab take for sleep known as an antidepressant. Lorazepam 0.5mg, 1 tab is given for anxiety as a PRN, and this medication is also prescribed the same dosage, but for 8a and 8p. The provider has no protocol for PRN medication administration.Notification of an adverse reaction to a medication may be made to the prescribing certified registered nurse practitioner (CRNP) when the medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners). The house manager will review MAR to assure all required information including physician is present. The MAR will be amended to include physician name 04/11/2025 Implemented
6400.162(a)The current staff have outdated medication administration test that are outdated based on the below test dates: 1. Staff one 7/17/23 2. Staff two 5/2/22A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Documentation was provided to demonstrate all staff medication administration training is current and up to date. 04/11/2025 Implemented
6400.163(a)The inspector could not read label on Vitamin D. ointment, the label was damaged for individual one.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 house manager will request a new label to replace the illegible label. 05/01/2025 Implemented
6400.163(b)6400.163.b Vit D was not stored in original box for individual one.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.The prescription in question does not come in a box. It is a glass bottle that contains the required prescription information 05/01/2025 Implemented
6400.165(f)165f Medication listed as PRN on the MAR with no protocol for individual two: Trazadone HCL 50 mg 1 tab take for sleep known as an antidepressant. Lorazepam 0.5 1 tab is given for anxiety as a PRN, and this medication is also prescribed the same dosage, but for 8a and 8p. The provider has no protocol for PRN medication administration.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Trazadone has multiple uses and Individual two takes it for insomnia and not for depression. It is outlined on the MAR stating purpose of use. The medication was discontinued on 5/19/25 by the prescribing psychiatrist. The medication was removed from the home, and the MAR has been updated. 05/01/2025 Not Implemented
6400.166(a)(13)The names of the staff administering medication was not consistent on the MAR, their full names were not listed for individual number two.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 house manager will confirm all staff first and last name are printed on MAR with initials that correspond to MAR 05/01/2025 Implemented
SIN-00256415 Renewal 11/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The fire department notice did not include specific information about the locations of the individuals' bedrooms.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 was a proposal for service only, and not an invoice or receipt 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
6400.111(a)There was no fire extinguisher in the attic.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Maintenance will install a fire extinguisher in the attic 12/01/2024 Implemented
6400.52(c)(1)Staff 7 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 7 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 7 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 7 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 7 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 7 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-00235282 Renewal 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Greater than 5 days elapsed between the hire and criminal background check dates for the following staff: Staff Members 1, 2, 3, 4, 5, 6, and 7. The following staff have criminal checks on file that were greater than one year old at the time of their hire: Staff Members 8 and 9. Staff Members 10, 11, 12, 13, 14, 15, and 16 were all hired in 2023 and do not have completed criminal background checks on file with the agency.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. Human Resource Manager reviewed file to assure new hire packet background check were completed within timeframe of hire date. Staff members 10-13 and 15-16 background checks were submitted with correction plan. Staff member 14 did was a previous employee who separated from the company on February 2023 and returned in July of 2023. Therefore, a new background check was not necessary. 01/01/2024 Implemented
6400.81(k)(6)There was 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
6400.104The agency's fire department notices do not list the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire.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 fire department notices will be resent to include layout of home identifying location of individual bedroom. 01/31/2024 Implemented
6400.151(a)Staff Member 6 does not have a physical on file. 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. Upon a review of the file by the HR Manager staff member 6 physical was located and submitted during correction plan. Additionally, Employee 6 took the physical form to doctor office to be completed. 01/24/2024 Implemented
6400.151(c)(3)Staff Member 15's 3/6/23 physical does not contain a signed statement from the doctor clearing them of communicable disease. The 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 disease to individuals. Staff member 15 took physical form to be fully completed by physician and returned. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. 01/31/2024 Implemented
6400.151(c)(4)Staff Member 15's 3/6/23 physical does not contain consideration of medical problems which might interfere with the health of the individuals.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Staff member 15 took physical form to be fully completed by physician and returned. A policy was developed stating all new hires must have Independence Support Services physical form completed that is in compliance with regulations. 01/31/2024 Implemented
6400.181(c)Individual 1's 10/1/23 assessment does not list the sources of its information.The assessment shall be based on assessment instruments, interviews, progress notes and observations. Program Specialist revised form to include how assessment was completed 01/01/2024 Implemented
6400.181(e)(12)Individual 1's 10/1/23 assessment does not contain recommendations for training, programs, or services.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
6400.165(c)Cannot determine if medication (Clonidine .1 tab) was dispensed to Individual 1. There is no blister pack to indicate corresponding date of medication for AM dosage. There was only a blister pack for 4 pm dosage that was unused.A prescription medication shall be administered as prescribed.Incident report was entered to reflect the medication error. House manager reviewed all medication to assure it aligned to MAR and administered accordingly. Director of Health services reviewed medication administration procedures with staff identifying breakdown and action steps to prevent a reoccurrence. This included reviewing all medication being accounted for prior to administration 01/31/2024 Implemented
6400.213(1)(i)Individual 1's file does not contain a record of 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