Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272906 Renewal 09/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were not locked up.Poisonous materials shall be kept locked or made inaccessible to individuals. All hazardous materials; were locked per individual #3 ISP instructions on 9/3/2025. All staff was trained on the physical site section of the 6400 regulations on 9/8/2025. 09/08/2025 Implemented
6400.64(a)There was baked in grease and grime in the oven.Clean and sanitary conditions shall be maintained in the home. On 9/3/2025, Oven cleaned and sanitized immediately. 09/03/2025 Implemented
6400.77(b)There were no tape, tweezers, thermometer or scissors in the first aid kit. 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. On 9/3/25 first aid kit replenished with tape, tweezers, thermometer, scissors and place in the home. 09/03/2025 Implemented
6400.113(a)Fire Safety training was conducted 2/5/2025. Previous training was not found. Individual #3 was admitted 7/15/2023. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Fire safety for Individual #3 was completed on 2/1/2024. Provider was trained by Fire Marshall 5/30/2023. 09/03/2025 Implemented
6400.141(a)Incomplete Physical for 5/9/2024 on file for Individual #3. No physical on file for 2025.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On 9/5/2025, A copy of 5/9/2025 physical retrieved from PCP, copy of form is added to individual file. 09/05/2025 Implemented
6400.142(h)No dental care plan is on record for #Individual #3. The dental hygiene plan shall be kept in the individual's record.On 9/4/2025 Dental-hygiene plan was obtained from the dentist and filed on 09/5/2025 a copy is kept individual #3 medical book. 09/05/2025 Implemented
6400.171There was cooked chicken left unwrapped in the microwave oven, and the individual was out in the community.Food shall be protected from contamination while being stored, prepared, transported and served. Food was discarded on 9/3/25 immediately and the microwave cleaned. All DSPs were retrained on safe food storage and handling practices from 6400 regulations on 9/4/2025. 09/04/2025 Implemented
6400.181(a)The record for Individual #3 was Missing the 2025 and 2024 annual assessments. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. On 9/3/25 Program Specialist and CEO Updated assessment to reflect current information on individual #4. 09/04/2025 Implemented
6400.32(e)There was plexiglass covering all the windows in the home, preventing the individual from opening their windows.An individual has the right to make choices and accept risks.Maintenance removed the plexiglass to restore window function and airflow on 9/4/2025. A work order was created to put safety glass into the windows on 9/4/2025 Window will be replaced on 10/25/2025. 09/04/2025 Implemented
6400.34(a)Individual Rights were last signed 6/5/2025 for Individual #3. The rights were previously signed 8/25/2023.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.Program Specialist reviewed and re-signed rights with the individual on 9/3/2025. A copy of form is kept in the individual #3 file at the office. 09/04/2025 Implemented
6400.165(g)The psychotropic medication reviews for Individual #3 only occurred on 5/27/2025, 7/8/2025 and 8/5/2025. Some documentation is also missing at times such as reason for prescription, need to continue prescription and doses.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.On 10/7/2025, Individual #3 completed a 90-day medication review. forms were place in a file in the office. 10/08/2025 Implemented
6400.166(a)(4)The PRN medication, Melatonin, was in with the medications, but not on the MAR for individual #3. The nurse entered the Melatonin information on the MAR during the inspectionA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Nurse entered the medication onto the MAR immediately during inspection and verified all other medications for accuracy. Med Techs were retrained on notifying nursing of new medications. MAR was updated on 9/3/2025 09/04/2025 Implemented
6400.166(a)(11)With the exception of Trazadone, Acetaminophen and Diphenhydramine, there were no diagnoses or purpose for the medications on the MAR of individual for Individual #3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.All MARs updated to include medication purposes and diagnosis on 10/1/2025. All MAR was placed in the medication book. 10/06/2025 Implemented
6400.181(f)The notification of the 2024 ISP meeting was not found for Individual #3.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Copy of the 2024 ISP meeting notice was located from email correspondence and filed on 09/5/2025. Program Specialist created a checklist ensuring all ISP notices are retained. 09/05/2025 Implemented
6400.183(c)The record for Individual #3 was missing the 8/12/2025 ISP sign-in. The 2024 sign-in was not found either.The list of persons who participated in the individual plan meeting shall be kept.On 9/3/2025 CEO reached out to Support Coordinator requesting a copy of the sign in sheet. Sign-in sheet obtained from the support's coordinator and filed in chart on 10/06/2025 10/06/2025 Implemented
SIN-00260822 Unannounced Monitoring 02/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The office closet contained a sippy cup with unknown contents that had been growing mold inside. The bathtub floor had a buildup of dirt that requires cleaning.Clean and sanitary conditions shall be maintained in the home. The house supervisor failed to complete periodic checks of the home after individual #1 left the program. On 2/14/25, the sippy up was removed from the closet and discarded. The bathroom floor was cleaned to remove the dirt buildup. 02/14/2025 Implemented
6400.67(a)There was an approximately 6" hole in the wall near the foot of Individual 1's bed. A work order was not produced, however the hole was fixed the same day as the inspection. Both dressers for the individual had broken drawers (bottom left drawer on one dresser, and the two lowest drawers on the other).Floors, walls, ceilings and other surfaces shall be in good repair. The house supervisor failed to submit a maintenance request to the maintenance department to have the hole fix in the wall in individual #1 bedroom. On 2/14/25 the hole was immediately repaired for hole in individual #1's bedroom. A maintenance request was submitted to fix Individual's #1 dresser. On 2/17/25, individual #1's dresser drawers were fixed by the maintenance department. 02/17/2025 Implemented
6400.70There was no dedicated, operable phone on the premise.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The house supervisor put the house telephone away in the closet to the home being unoccupied since September 2024 On 2/14/25, the house phone was immediatelyt reconnected in the home. 02/14/2025 Implemented
SIN-00244483 Renewal 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff Person #3 was hired on 12/29/23 and a Criminal background check was not requested until 4/16/2024.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. Martha's way failed to obtained the criminal history record for staff #3. On 5/14/24 Martha's Way human resource department was reeducated on the regulations and compliance of obtaining criminal history clearance prior to the date of hire. Implemented
6400.112(e)Review of fire drill logs does not indicate at least one sleep drill occurred in the past six months. The drill conducted 5/13/24 was done at 10am. 4/14/24 -- 1:34pm, 3/14/24 -- 2:10pm, 2/4/24 -- 9:25am, 1/4/24 -- 5pm, 12/4/23 -- 8:32am, 11/4/23 -- 7:40pm, 10/14/23 -- 11:12pm.A fire drill shall be held during sleeping hours at least every 6 months. Martha's Way failed to note on the fire drill form on 10/14/23 that this was an overnight drill as the individual was asleep in the home. Martha's Way house supervisor and staff was reeducated on how to properly document an overnight asleep fire drill. 05/28/2024 Implemented
6400.141(c)(10)No record of completion of annual physical for individual #3 stating they are free from communicable diseases. According to the ISP, the last physical was completed 11/17/2022.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Martha's Way failed to obtain a copy of individual #3 physical exam form prior to admission. Individual #3 annual physical exam was completed on 04/11/2024. 05/30/2024 Implemented
6400.181(a)No record of initial assessment completed a year prior to admission or 60 days within of admission for Individual #3. The only item provided was an ISP with a print date of 9/7/2023. The document combines details from 2020. She entered the home in 10/2023. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist failed to place a hard copy of individual #3 initial assessment in their record. On 5/15/24, a hard copy of individual # 3 initial assessment was placed in individual's file kept in the home. The program specialist was reeducated by the CEO on the filing system of individual's records kept in the home. 05/15/2024 Implemented
6400.165(e)The following prescription for Individual #3 was not available. Lithium Carb Tab 300 MG ER -- Take 1 tab twice a day was not found with during medication review. Staff stated that it was discontinued, however the medication does not reflection discontinuation on the MAR.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Marthas Way failed to discontinued the individual #3 Lithium Carb Tab 300 MG ER on the medication record. On 5/14/24, the House Supervisor discontined individual #3 Lithium Carb Tab 300 MG ER on the medication record. On 4/12/24 individual #3 Lithium Carb Tab 300 MG ER was discontinued by the CRNP. 05/14/2024 Implemented
6400.165(g)No record of quarterly reviews for medications prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician documenting the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Only one document from 9/2023 found in the record meets the criteria for Individual #3.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 new house supervisor failed to take along to the quarterly psychotropic medications reviews appointments the agency's psych med review form. On 3/5/24, individual #3 had a medication review of her psychotropic medication by the UPMC Cedar emergency room department during a visit. On 5/22/24 individual #3 had a medication review of her psychotropic medications. On 5/15/24, the house supervisor and staff was reeducated on the use of the agency's standard quarterly psychotropic medication review form as well as the completion of the form. 05/30/2024 Implemented
6400.183(c)No list of persons who participated in the last individual plan team meeting was found on file for Individual #3.The list of persons who participated in the individual plan meeting shall be kept.Martha's Way program specialist failed to obtain a copy of the individual #3 ISP signature sheet. On 5/15/24, Martha's Way CEO obtained a copy of individual #3 ISP signature from the SC and placed a copy in the record. 05/30/2024 Implemented
6400.213(1)(i)The file for Individual #3 is missing documentation of hair color, eye color and identifying remarks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Martha's Way agency's individual demographic form failed to contain information to record an individuals hair color, eye color and identifying marks. On 5/14/24 Martha's Way revised the individual's demographic form to include hair color, eye color and identifying marks. Individual #3 demographic form was completed on the new form to contain the missing identification information. The house supervisor removed all old paper versions of the demographic form from the home. 05/28/2024 Implemented
SIN-00274459 Unannounced Monitoring 09/25/2025 Compliant - Finalized
SIN-00250229 Unannounced Monitoring 08/21/2024 Compliant - Finalized