Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245073 Unannounced Monitoring 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171On 5/14/24 at 10:09 AM, a pot filled a quarter of the way with used frying oil that had food particles floating in it was observed on the top shelf inside the oven atop three pieces of wax paper. [Repeated Violation-11/16/23, et al & 4/10/24 et al]Food shall be protected from contamination while being stored, prepared, transported and served. On 5/14/24, the staff on duty emptied the pot filled with used frying oil into the trash. 05/14/2024 Implemented
SIN-00241845 Unannounced Monitoring 02/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 2/29/24 at 10:56 AM, Individual #1's exposed mattress, throw blankets, and pillows were found with several brown-colored stains that appeared to be feces. At 10:50 AM, in the apartment's only bathroom tub, several areas of white caulking were observed covered in black stains that appeared to be mold or mildew. Additionally, at 10:51 AM, the bathtub's white shower curtain was discovered discolored with hard-water stains and several small black spots that appeared to be mold or mildew. The shower curtain also appeared glossy and shiny, having a pungent odor. [Repeated Violation-9/20/23, et al & 11/16/23, et al]Clean and sanitary conditions shall be maintained in the home. On February 29, 2024, Solidarity Management replaced the mattress and shower curtains, and the staff on duty changed all bedding in Individual #1 `s home (See email on 3/1/2024). Solidarity Management contacted the Handyman on 2/29/2024 and the bathtub showing black stains that appeared to be molds was refurbished on 3/4/2024 (See email on 3/5/2024). 02/29/2024 Implemented
6400.64(c)On 2/29/24 at 10:44 AM, the following items were observed scattered all over the rear porch: a broken bed frame and futon, a broken three-drawer plastic bin, two creased blind slats, a television, a bed box spring, and a mattress.Trash shall be removed from the premises at least once per week. On February 29, 2024, all items scattered around the porch were removed. 02/29/2024 Implemented
6400.67(a)On 2/29/24 at 12:07 PM, the handle was observed missing from the closet in the laundry room. [Repeated Violation-11/16/23, et al]Floors, walls, ceilings and other surfaces shall be in good repair. Solidarity Management replaced the laundry room closet doorknob on March 4, 2024. (See email on 3/14/2024). 03/04/2024 Implemented
6400.76(a)On 2/29/24 at 11:28 AM, the backs of two dining room chairs were found cracked and unstable. Furniture and equipment shall be nonhazardous, clean and sturdy. On February 29, 2024, Solidarity Management replaced the living room couch and dining room chairs (See email on 3/1/2024). 02/29/2024 Implemented
6400.81(k)(2)On 2/29/24 at 10:53 AM, individual #1's mattress was observed to be too large for the bedframe with its excess portion extending beyond the box spring and bending over the right side of the bed.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. On 2/29/2024, Solidarity Management replaced the mattress to fit the bedframe (See email on 3/1/2024). 02/29/2024 Implemented
6400.81(k)(3)On 2/29/24 at 10:54 AM, Individual #1's bed was found without a fitted bedsheet resulting in direct exposure to the mattress.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.On February 29, 2024, the staff on duty changed all bedding in Individual #1 `s home including a fitted bedsheet. Solidarity Management also replaced the mattress and bedsheets (See email on 3/1/2024). 02/29/2024 Implemented
6400.143(a)Individual #1 signed a document on 10/9/23 indicating they do not attend dental appointments due to a phobia caused by their father dying of a mouth disorder. There has been no continued attempts to train the individual about the need for a dental examination.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The Program Specialist and Behavior Specialist had a follow up conversation with individual #1 on 3/25/2024 on the consequences of not attending dental appointments. A record of the conversation is documented in the home in Individual #1¿s file. 03/25/2024 Implemented
6400.171On 2/29/24 at 10:41 AM, an uncovered head of cabbage was observed in the refrigerator's right-side crisper drawer. Additionally, a bag of decomposing green beans covered in a white, milky liquid that had seeped out and onto the bottom of the refrigerator's right-side crisper drawer was observed. At 10:42 AM, a freezer burnt bag of stir-fry mix clumped together in ice crystals was found in the freezer. [Repeated Violation-11/16/23, et al]Food shall be protected from contamination while being stored, prepared, transported and served. On 2/29/2024, the staff on duty removed all expired food items from the refrigerator. 02/29/2024 Implemented
6400.214(b)On 2/29/24, the following of Individual #1's current records were not found at the home: physical examination, and hearing screening or examination. [Repeated Violation-11/16/23, et al] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual #1¿s physical examination record done on 12/29/2023 obtained from the PCP on 3/18/2024 (See email sent on 3/20/2024). 03/18/2024 Implemented
6400.216(b)On 2/29/24, Individual #1's records were found unsecured in a clear plastic bin with three shelves located in the living room, in an unlocked hallway closet, and in an unlocked entryway closet near the dining room. [Repeated Violation-9/20/23, et al]The individual, and the individual's parent, guardian or advocate, shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld.On 2/29/2024, Solidarity Management bought filing cabinets and all individual records are securely stored and locked (See email on 3/1/2024). 02/29/2024 Implemented
6400.163(d)On 2/29/24 at 11:04 AM, the following were observed visibly exposed hanging on a hook on a wall in the dining room near the kitchen: keys to the locking filing cabinet securing Individual's medications, the agency vehicle keys, and other unknown keys. [Repeated Violation-9/20/23, et al]Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On 2/29/2024, the staff on duty removed all keys to the locking filing cabinet securing Individual's medications, the agency vehicle keys, and other unknown keys to a secured location that is not visibly exposed in the home. The holder stuck to the wall for carrying the keys was also removed on 2/29/2024. 02/29/2024 Implemented
6400.166(b)On 2/29/24, Individual #1's February 2024 Medication Record was missing a staff signature key to identify the initials of those who had administered medications. [Repeated Violation-9/20/23, et al]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.On 2/29/24 the missing staff signature key on the back of the Medication Administration Record (MARs) was updated by the Medication Administration Trainer and the staff. 02/29/2024 Implemented
SIN-00237806 Unannounced Monitoring 11/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)On 11/16/23, the following of Individual #1's current records were not found at the home: individual plan, assessment, physical examination, vision and hearing screenings or examinations, and dental examination as well as copies of their psychological evaluation and demographics page. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual #1¿s record was updated but individual was discharged from the Residential Habilitation Home on 12/21/2023. 11/20/2023 Implemented
SIN-00231311 Renewal 09/20/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Support Professional #1, date-of-hire 6/7/23, did not have a Pennsylvania criminal history record check. Direct Support Professional #2, date-of-hire 6/25/23, did not have a Pennsylvania criminal history record check.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. The HR Supervisor did the background check for Direct Support professional #1 and #2 on 9/20/2023. Attached. The two staff initially did the FBI Fingerprint since they were not resident in PA for 2 years. 09/26/2023 Not Implemented
6400.71On 9/21/23, none of the home's phones included any emergency numbers posted on them or nearby.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. The Emergency contact numbers were posted in the home on 9/22/2023. 09/22/2023 Not Implemented
6400.151(a)Direct Support Professional #3, date-of-hire is 10/20/22, did not have a physical examination prior to employment. 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 notified the Direct Support Professional #3 on 10/11/2023 to provide a copy of the physical done prior to hiring. Direct Support Professional #3 contacted Med Express and document will be available within 10 days. Expected by 10/25/2023. 10/25/2023 Not Implemented
6400.151(c)(2)Direct Support Professional #3, date-of-hire is 10/20/22, did not have a completed tuberculosis test with negative results prior to employment. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The Program specialist notified the Direct Support Professional #3 on 10/11/2023 to provide a copy of the Tuberculin test with a negative result done prior to hiring. Direct Support Professional #3 contacted Med Express and document will be available within 10 days. Expected by 10/25/2023. 10/25/2023 Not Implemented
6400.216(a)On 9/21/23, Individual #1's records were observed unsecured and in plain sight on the kitchen counter at 11:23 AM. An individual's records shall be kept locked when unattended. The Home Supervisor purchased a storage cabinet on 10/12/2023. Receipt attached. Individual #1¿s records are now placed in the locked cabinet inside the home. 10/12/2023 Implemented
6400.18(a)(5)EIM Incident #: 9229469 for neglect was discovered on 6/8/23 at 8:00 AM and reported on 6/9/23 at 11:59 AM.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 24 hours of discovery by a staff person: Neglect. The Certified Investigator organized a training on 10/9/2023 to discuss ODP Incident Management Bulletin # 00-21-02 that defines reporting timelines for various categories of incidents. 10/09/2023 Implemented
6400.18(a)(13)EIM Incident #: 9214291 for a rights violation was discovered on 5/9/23 at 5:00 PM and reported on 5/12/23 at 1:38 PM.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 24 hours of discovery by a staff person: A violation of individual rights.The Certified Investigator organized a training on 10/9/2023 to discuss ODP Incident Management Bulletin # 00-21-02 that defines reporting timelines for various categories of incidents. 10/09/2023 Implemented
6400.46(b)Direct Support Professional #1 completed annual fire safety training on 7/29/22 and has not yet done so for 2023.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The CEO contacted the Hempfield Fire safety Department on 10/9/2023 to plan a ¿train the trainer¿ class for Solidarity Employee to serve as inhouse Fire safety trainer. In the interim, a Fire safety training will be conducted by an outside Fire Specialist on October 25, 2023. 10/25/2023 Implemented
6400.51(b)(1)Direct Support Professional #3, date of hire 10/20/22, did not have orientation training in community integration.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.Direct Support Professional #3 was notified by HR Supervisor on 10/6/2023 to complete annual training to include community integration. 12/31/2023 Implemented
6400.51(b)(5)Direct Support Professional #3, date of hire is 10/20/22, did not have orientation training in individual-specific reviews of behavior support plans as well as individual plans.The orientation must encompass the following areas: Job-related knowledge and skills.The Home Supervisor organized a training on Individual #1¿s ISP on 9/22/2023. 09/22/2023 Implemented
6400.169(a)Direct Support Professional #3 completed the online examination of their initial medication administration practicum on 10/14/22. However, Direct Support Professional #3 has not completed the required medication passing observations for full completion of their initial Department-approved medication administration course within the allotted time frames as outlined by the Department. Direct Support Professional #3 has been administering medications.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Direct support Professional #3 completed the initial Medication Administration face-face training and 4 observations prior to administering medications. CEO #4 who is ODP Medication Administration Trainer contacted ODP Medication Administration Help desk on 10/9/2023 for clarification. Response will be submitted as an attachment. 10/09/2023 Implemented