Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247709 Renewal 07/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)Bathtubs and showers shall have a nonslip surface or mat. The bathtub did not have a non slip mat at the time of inspection. Bathtubs and showers shall have a nonslip surface or mat. Nonslip mat was located following the inspection, in the basement due to it having been cleaned. A picture was sent on the day of inspection to show that this item was present in the basement, in the dryer. 09/01/2024 Implemented
6400.111(f)A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguishers located in the kitchen, attic and basement all were last inspected in Jan 2023. The agency did correct this issue immediately after being informed the extinguishers were not inspected. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Provider agency immediately corrected issue with expired fire extinguisher inspection on date of discovery by licensing. 09/01/2024 Implemented
6400.151(a)A staff member shall have a physical exam 12 months prior to employment and every 2 years thereafter. Staff had a physical exam on 10/30/21 and then not again until 7/23/24. This exceeds the time frame under the regulation. 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. The Program Specialist had a physical exam completed on 10/30/21 and not again until 7/23/2024. Unfortunately, there is no way to go back in time and change the date in which the physical exam was completed. The only way to appropriately correct this issue is by prevention of re-occurrence. Please see provider's plan to maintain compliance. 09/01/2024 Implemented
6400.46(b)Program specialist shall be trained annually by fire safety expert. Staff had a fire safety training on 3.5.22 and not again until 5.2.23. This exceeds the annual time frame.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Program Specialist completed fire safety training on 3/5/2022 and not again until 5/2/2023. Unfortunately, there is no way to go back in time and change the date in which the fire safety training was completed by the Program Specialist. The only was to appropriately correct this issue is by prevention of re-occurrence. Please see provider's plan to maintain compliance. 09/01/2024 Implemented
6400.166(a)(7)The dose of medication shall be recorded on the medication administration record (MAR). Individual #1 is prescribed Biotin 1,000mcg tablets, half a tablet to be taken by mouth daily. The MAR reflects the individual shall take one tablet by mouth daily. The dose is not consistent with the blister pack.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.7/24/2024 provider corrected current MAR to reflect correct dose of medication, as consistent with the blister pack. 09/01/2024 Implemented
SIN-00227388 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1 was hired on 2/23/2023, has been working with individuals, and has not had a physical examination. 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. On 7/7/2023 Staff #1 completed their physical examination. 08/31/2023 Implemented
6400.51(b)(1)Staff #1 did not complete training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships as part of orientation training.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.On June 18, 2023 Staff #1 completed training that encompasses the following areas: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. 08/31/2023 Implemented
6400.51(b)(2)Staff #1 did not complete training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adult Protective Services Act, the Child Protective Services Law and the Adult Protective Services Act as part of orientation training.The orientation 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.On 6/18/2023, Staff #1 completed training in the prevention, detection, and reporting of child abuse, suspected abuse, and alleged abuse. 08/31/2023 Implemented
6400.51(b)(4)Staff #1 did not complete training in recognizing and reporting incidents as part of orientation training.The orientation must encompass the following areas: recognizing and reporting incidents.On 6/18/2023 Staff #1 completed training in recognizing and reporting incidents. 08/31/2023 Implemented
Article X.1007In accordance with the Older Adult Protective Services Act, new employees shall have a PA State Police criminal history record check completed on or before the first day of work. Staff #1 was hired on 2/23/2023 and did not have a PA State Police criminal history record check completed until 3/30/2023.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.PA State Police criminal history check was completed on 3/30/2023 08/31/2023 Implemented
SIN-00220087 Unannounced Monitoring 02/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisons were not in their original labeled containers. A decorative liquid soap dispenser was found with an unknown liquid hand soap in the bathroom located in the basement of the home. An unlabeled spray bottle filled with an unknown clear liquid was found with cleaning supplies on a shelf above the stairs to the attic/2nd floor of the home.Poisonous materials shall be stored in their original, labeled containers. Both containers were immediately removed from the premises. Please note that the decorative soap container was in a restroom which is utilized only by provider staff. The soap contained in the pump was plant-based/non-toxic. The unlabeled spray bottle was maintained in the attic of the home, which is a staff office area. The water bottle container water for watering houseplants that were inside of the staff office space. 03/08/2023 Implemented
6400.71Emergency telephone numbers were not posted on or near the telephone located in the living room of the home.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. Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center were posted on and by the telephone located in the living room of the home on 2/24/2023. Please note that the individual living in the home frequently pulls down signs and other wall decorations in the home, which is why the emergency numbers were no longer in place. 03/21/2023 Implemented
6400.110(e)The home has three levels including the basement and the attic/2nd floor, and the smoke detectors were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. On 2/24/2023 agency maintenance re-connected the existing interconnected smoke detectors in the home. They were re-tested multiple times to ensure that they were once again properly interconnected. 02/24/2023 Implemented
6400.213(6)The initial/annual assessment developed for Individual #1 was not available as part of the individual's record in the home.Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). Individual #1¿s initial assessment was printed and placed in the home, effective 2/28/2023. The initial assessment had previously been completed but was not printed and placed in the individual¿s documentation in the home. 03/01/2023 Implemented
SIN-00212819 Unannounced Monitoring 09/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Per the Individual Support Plan (ISP), Individual #1 requires poisonous materials to be locked for his safety. At the time of inspection, a can of Lysol Disinfectant Spray was located on a windowsill in the dining room area of the home, unlocked, in plain view, and easily accessible to Individual #1. (Repeat Violation: 07/22/2022)Poisonous materials shall be kept locked or made inaccessible to individuals. At the time of discovery, the Lysol was placed in the cabinet and locked. AND currently stores all poisonous materials in a locked cabinet underneath the kitchen sink with overflow/extra cleaning products stored in a locked closet, including the Lysol Disinfectant Spray. 11/30/2022 Implemented
6400.71There were no emergency telephone numbers posted on or near the telephone located in the home's living room area.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. Emergency Telephone Numbers are posted on the wall near the telephone, as well as on the telephone handset effective 10/7/2022. 11/30/2022 Implemented
6400.18(b)(2)On the evenings between 8/16/22 and 8/18/22, Individual #1 was administered Depakote ER 250mg tabs instead of the prescribed Depakote DR 250mg tabs At the time of inspection, no incident entry was present in Enterprise Incident Management (EIM) for this medication error.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 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.On 10/17/2022, provider entered EIM# 9106129, 9106170, 9106174, reporting the medication errors through the Department¿s Information management system on the form specifically specified by the Department. 11/30/2022 Implemented
6400.167(b)At the time of inspection, Individual #1's Individual Record did not contain documentation of the medication error occurring from 08/16/2022 through 08/18/2022, during which the individual was incorrectly administered "Depakote ER 250mg" instead of "Depakote DR 250mg" at three evening administrations. There was no documentation of any follow-up action taken as a result of this incident nor of the prescriber's response contained within the Individual Record.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.On 10/17/2022, provider entered EIM# 9106129, 9106770, 9106174, reporting the medication error through the Department¿s Information management system on the form specifically specified by the Department. Report included documentation of the medication error, follow-up action taken and the prescriber¿s response. 11/30/2022 Implemented
6400.186Individual #1 is diagnosed with a seizure disorder. The Individual Support Plan (ISP) outlines precautions that caregivers should take in order to avoid potentially triggering a seizure. The "Health Promotion" section of the ISP notes that the following strategy of support is required with respect to Individual #1's seizure disorder: "···AVOID EXCESSIVE FLASHING LIGHTS, STRONG SMELLS INCLUDING HEAVY PERFUMES/COLOGNES, AND OVER HEATING." At the time of inspection, the following scented cleaning products and/or air fresheners were found in the home: "Pledge: Clean it -- Fresh Citrus Scent," "Febreze: Fabric -- Gain Scent Parfum," and "Glade -- Hawaiian Breeze Scent." Staff on site stated that these products were used routinely in the home. As the labels of each of these products advertises the scent as a feature of the product, it can be concluded that the scent of each product is intended to be recognizably strong at a distance, approximately comparable in strength to a heavy perfume or cologne that could be smelled at a distance. The ISP specifies that Individual #1 should be protected from scented products of this nature; by using the aforementioned scented products within the home, the provider failed to implement the plan as written.The home shall implement the individual plan, including revisions.Effective 10/7/2022, all cleaning products containing strong smells and heavy perfumes have been removed from the home and will no longer be purchased for use in the home. 11/30/2022 Implemented