Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290762 Technical Assistance 06/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The home's dryer hose was detached resulting in its exhaust and lint entering the general basement area and clinging to the wall.Floors, walls, ceilings and other surfaces shall be in good repair. Following the licensing inspection, the Program Administrator immediately notified the landlord/property maintenance representative of the detached dryer exhaust hose. The repair was completed on July 2, 2026, by reattaching the dryer exhaust hose to ensure that lint and exhaust are properly vented outside of the residence. Photographic documentation verifying completion of the repair has been maintained. 07/20/2026 Implemented
6400.104The fire department notification dated January 2, 2026, for the residence was addressed to Chester Fire Department, One Fourth Street, Chester, PA 19013, which is Chester City Hall. The agency's Emergency Plan---Chester 21 listed Chester Fire Station 81, 1501 W 3rd Sr., Chester PA 19013.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 LIFE Group completed an immediate review of the annual Fire Department Notification process for all applicable residential locations. Corrected Fire Department Notification letters were prepared and reissued to the appropriate local fire departments serving each licensed home. Copies of all revised letters were retained, along with proof of mailing for each location. The corrected notification letters were printed on July 1, 2026 and mailed on July 6, 2026 by Executive Oversight. 07/06/2026 Implemented
6400.142(a)Dental visits in Individual #1's record were dated 12/4/2024 and 5/28/2025. There was a fax request for all dental visit information dated 7/2/2025. The response to the fax; was dated 1/30/2026 and the response indicated that last visit/exam was completed on 5/28/2025. No verification of the next appointment dated 6/4/2025.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The LIFE Group Program Manager immediately scheduled a dental appointment for Individual 1 and obtained documentation confirming the appointment. The appointment occurred on Wednesday, July 8, 2026 at 9:30 AM with Dream Smile Dental (see attached medical encounter form). To support tracking and follow-up, all appointments was also entered into Google Calendar by the Program Manager to which the Program Specialist, HR and Program Manager are all invited to (see attached) 07/10/2026 Implemented
6400.167(a)(1)Instances of medications not administered as prescribed were observed for the individual #1. On June 13, 2026, the 8 P.M. dose of Clonidine 0.2mg remained in the blister pack although Staff initialed having given the medication. On June 30, 2026, 8 A.M. dosages of Atorvastatin 20mg and Buspirone HCL 10mg were still in the blister pack although Staff initialed having given the medication.Medication errors include the following: Failure to administer a medication.Upon identification of the deficiency during the licensing inspection, The LIFE Group immediately reported the medication administration errors involving Individual #1 through the HCSIS/EIM Incident Management System. The medication errors were entered into EIM on July 3, 2026, under Incident ID #9877931 and Incident ID #9878895, allowing the incidents to be formally reviewed, investigated, and addressed through the agency's Incident Management process. The Incident Manager was assigned responsibility for completing the incident management process, with support from the Program Manager. All required notifications, documentation, and follow-up activities were completed in accordance with agency policy. The staff members responsible for the medication administration errors received immediate retraining on the agency's Medication Administration Policy, including the Five Rights of Medication Administration, medication documentation requirements, medication verification procedures, and the importance of ensuring medications are administered before documenting them on the Medication Administration Record (MAR). Staff also received retraining on Incident Management requirements related to medication errors. Following retraining, the staff member identified for the error successfully completed a medication administration competency observation on July 17, 2026, demonstrating competency before resuming independent medication administration duties. 07/31/2026 Implemented
6400.167(c)The medication errors on June 13, 2026, and June 30, 2026, were not reported for Individual #1. On June 13, 2026, the 8 P.M. dose of Clonidine 0.2mg remained in the blister pack although Staff initialed having given the medication. On June 30, 2026, 8 A.M. dosages of Atorvastatin 20mg and Buspirone HCL 10mg were still in the blister pack although the Staff initialed having given the medications.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Upon identification of the deficiency during the licensing inspection, The LIFE Group immediately reported the medication administration errors involving Individual #1 through the HCSIS/EIM Incident Management System, as required by 55 Pa. Code §6400.167(c) and §6400.18(b). The medication errors were entered into EIM on July 3, 2026, under Incident ID #9877931 and Incident ID #9878895, allowing the incidents to be formally reviewed, investigated, and managed through the agency's Incident Management process. The Incident Manager was assigned responsibility for completing the incident management process, with support from the Program Manager. All required notifications, documentation, and follow-up activities were initiated in accordance with agency policy. Corrective action for the reporting deficiency was completed on July 3, 2026. The staff members responsible for the medication administration errors, as well as the failure to report the medication errors as incidents, received retraining on the Medication Administration Policy and Incident Management Policy, including reportable medication error categories and reporting timeframes. Following retraining, each staff member successfully completed a medication administration competency observation on 7/17/2026 to verify understanding of medication administration procedures and incident reporting requirements before resuming independent medication administration duties. 07/20/2026 Implemented
SIN-00280151 Unannounced Monitoring 12/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Prodigy Twist Top 28g Lance 12 PM was not signed off on the MAR for 12/18/25 and there was no explanation in the Nurse's Medication Notes for individual 1.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Immediate Corrective Action The LIFE Group Quality Manager immediately reviewed the individual's medication administration record (MAR) and spoke to staff responsible for medication administration on 12/18/25. The staff was informed about failure of proper MAR documentation. The Program Specialist and Nurse was notified to review the MAR and all prescribed medication by 2/6/26 01/30/2026 Implemented
6400.167(a)(1)Individual 1 - 100 MG, 8 PM dose was signed off on the MAR on 12/10/25 and the tablet was left in the blister pack. Buspirone 5 MG, 12 PM dose was not signed off on the MAR on 12/18/25 as being refused and the tablet was left in the blister pack. Clonidine 0.1 MG, 12 PM dose was not signed off on the MAR on 12/18/25 and the tablet was left in the blister pack.Medication errors include the following: Failure to administer a medication.Immediate Corrective Action The LIFE Group Quality Manager immediately reviewed the individual's medication administration record (MAR) and spoke to staff responsible for medication administration on 12/10/2026 and 12/18/2026. The missed medication will be entered into EIM on 1/30/26. The Program Specialist and Nurse was notified to review the MAR and all prescribed medication by 2/62026 01/30/2026 Implemented
SIN-00277620 Unannounced Monitoring 11/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light outside of the back door was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Immediate Correction- 11/10/25 1. Immediate Correction After the inspection, staff from The LIFE Group replaced the light bulb and verified with the PM that the exterior back door light is operational. Adequate lighting is now provided to ensure the safety of individuals. 11/10/2025 Implemented
6400.67(b)The area between the kitchen back door and the screen door had a plastic floor cover that was semi-folded up and not level which is a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.1. Immediate Correction- After the inspection, staff immediately corrected the hazard by removing the plastic mat and replacing it with another spare mat from the basement. The area is now free from tripping hazards. 11/10/2025 Implemented
6400.105The lint trap of the dryer was full of lint.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Immediate Correction- 11/10/25 At the time of inspection, staff from The LIFE Group immediately cleaned the dryer lint trap and removed all accumulated lint. The dryer is now in a safe and non-hazardous condition. 11/10/2025 Implemented
SIN-00262255 Unannounced Monitoring 03/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)· The water temp was 122 degrees at the time of the review.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The House Manager adjusted the water heater to read below 120 degrees on the same day when notified by the inspector on 3/14/25. 03/14/2025 Implemented
6400.190(c)The house daily activity notes and the provider's Therap reports did not show on-going opportunities for engagement in recreation and social activities in the community. The record showed one activity per week for the past couple of weeks. The last activity plan that was on site was from January 2025. The individual was able to express their likes and dislikes in this area and does want to engage in community life activities in the community with supports.Documentation of recreational and social activities shall be kept in the individual¿s record. All staff that work was trained on how to properly document daily activities electronically during onboard training with the Program Specialist. All staff will complete a retraining by Friday 4/4/25 that discusses the importance of Community Integration for all individuals and how to properly document the activity and refusals. 04/15/2025 Implemented
SIN-00259509 Unannounced Monitoring 01/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)One of the trash cans outside of the home was full and did not have a lid to cover the contents.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The organization will ensure that trash outside the home is kept in closed receptacles that prevent penetration of insects and rodents. A lid was provided to the trashcan that was lidless. 01/31/2025 Implemented
SIN-00252373 Unannounced Monitoring 09/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101101 There was a deadbolt locked on the back door storm door. The home had no key that would be needed to unlock the door to evacuate the home if the door is locked in case of a fire or any other life safety emergency.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The LIFE GROUP will ensure that doorways are unobstructed. The deadbolt lock was replaced with a lock that does not require a key to open from the inside. 10/14/2024 Implemented
6400.144144. Health services. The prescription label's Prodigy Test Strips state that they should be used 4 per day with insulin; however, the individual is only prescribed to take insulin 3 times a day. Prodigy twist Top 28g Lance and Prodigy No Coding Test Strip's medication labels states use to test blood glucose four times daily for individual number 1; however, since 09/10/24 the lancets and strips were only being used 3 times daily to test blood glucose. There were no blood glucose tests done for Individual #1 on 09/12/24.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. The LIFE GROUP will ensure that all Health services are planned or prescribed for the individuals is arranged for or provided. The correction was made on the MAR to reflect the current order of use of the strips 3x a day instead of 4x a day. 10/15/2024 Implemented
6400.214(a)Individual #1 behavioral data sheets with notes were not in the home for the month of September.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.The LIFE GROUP will ensure that all items related to contents of the records are in the home at all times. THE BSS WILL RETRAIN ALL STAFF ON THE IMPORTANCE OF COMPLETING THE DATA COLLECTION SHEETS EVERY SHIFT. 10/31/2024 Implemented
6400.214(b)Individual #1's medical records were not in the home at the time of the review. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The LIFE GROUP WILL ENSURE THAT THE MOST CURRENT RECORD INFORMATION IS IN THE RESIDENTIAL. HOME. A COPY OF THE MEDICAL WILL BE PLACED IN THE HOMES PER REGULATION. AND UPDATED ACCORDINGLY. 10/10/2024 Implemented
6400.166(a)(13)166(a)(13). Medication record. Chlorpromazine 25 mg, Ferosul Sulfate 325 mg, and Fish Oil 1,000 mg were taken form the blister packs on 09/24/24 for the 8 AM dosage, but they were not initialed as being administered on the MAR.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 LIFE GROUP will ensure that name and initials of the person administering the medication is consistently on the MAR. 10/09/2024 Implemented
SIN-00245296 Unannounced Monitoring 05/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34Front bedroom closet door doesn't open. Unable to gain access to the closet to determine what's inside.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The L.I.F.E Group will ensure authorized agents have full access to the facility. The front bedroom closet was repaired to open and close with ease. 06/07/2024 Implemented
6400.64(a)The kitchen cabinets are dirty on the surfaces and on the insides. The basement bathroom floor, toilet and sink are dirty. There is dust throughout the entire home. The floor is dirty as are the walls, and there are spider webs -- the overall condition of the home was not clean. There was a smell on the second floor that was stale.Clean and sanitary conditions shall be maintained in the home. The L.I.FE. Group will ensure that clean and sanitary conditions are maintained throughout the home. The home is not occupied by an individual at this time and is having multiple repairs completed therefore the surfaces with dust and spider webs will be cleaned and sanitized. 06/07/2024 Implemented
6400.67(a)Dresser drawers inside of bedroom won't close. 2nd floor shower head needs to be repaired. There is a hole surrounding the base of the shower head that exposes the inner bath wall.Floors, walls, ceilings and other surfaces shall be in good repair. The L.I.F.E Group will ensure floors, walls, ceilings and other surfaces are in good repair. The showerhead and the base were repaired. The dresser drawers will be repaired. 06/07/2024 Implemented
6400.72(b)Front and Back screen door does not close. The second window of the sun porch (the window that is screened) is inoperable. The screen is on the inside and the storm window is on the outside which makes it very difficult to open the window for ventilation. Screens, windows and doors shall be in good repair. The L.I.F.E Group will ensure screens, windows and doors are in good repair. Both doors will be replaced. The sunporch window is now operable. 06/30/2024 Implemented
6400.76(a)The dining room table is not sturdy. Furniture and equipment shall be nonhazardous, clean and sturdy. The L.I.F.E Group will ensure that furniture and equipment are nonhazardous, clean and sturdy. The dining table was discarded and will be replaced with a sturdy table 06/30/2024 Implemented
6400.77(a)There was no first aid kit in the home. A home shall have a first aid kit. The L.I.F.E Group will ensure that all homes have a first aid kit on the premises. A first aid kit was purchased and placed in the home. 05/31/2024 Implemented
6400.80(b)Grass in rear and front yard is too high and needs to be cut. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The L.I.F.E GROUP will ensure that the outside of the home will be well maintained, and free from unsafe conditions. The front and back of the property has been landscaped. 06/04/2024 Implemented
6400.81(i)Mini blind is broken in middle bedroom.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The L.I.F.E GROUP will ensure Bedroom windows shall have drapes, curtains, shades, blinds or shutters intact. The broken blind was replaced with new blind. 06/10/2024 Implemented
6400.82(f)The basement bathroom has no toilet paper or paper towels.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. The L.I.F.E GROUP will ensure that each bathroom has a sink, wall mirror, soap, toilet paper and paper towel. Missing items toilet paper and paper towel were obtained and placed in the basement bathroom 05/31/2024 Implemented
6400.111(a)No fire extinguisher in kitchen. No fire extinguishers in the home on any floor.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The L.I.F.E GROUP will ensure there is at least one fire extinguisher on each floor of the home including the basement. The fire extinguishers received the annual check and was placed back in the home. 05/31/2024 Implemented