Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257178 Renewal 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's August 2024 financial records balance was documented as $1.29 at the end of the month, and their September 2024 financial records start balance was documented as $.21. Individual #1's September 2024's financial records start balance should have been $1.29. The home is not keeping an up-to-date financial record for Individual #1.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. It was determined that the individual made a purchase online in July and the receipt was not placed into his financial binder. The receipt was subsequently obtained and his financials were corrected and brought up to date. 12/30/2024 Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. The caulking around the tub in Individual #2's bathroom was pulling out from the wall in approximately 2 areas, and this same caulking also had multiple areas of a black like substance on it resembling mold/mildew. Upon opening Individual #1's bedroom door and entering their bedroom it had a strong pungent odor of what appeared to be body odor or an odor similar. The smell did not leave the room and the licensing representative even entered the room on two separate occasions.Clean and sanitary conditions shall be maintained in the home. The caulking on the tub in the bathroom was redone by maintenance on 12/10/2024. The odor in the individual¿s bedroom was determined to be coming from the individual¿s unwashed laundry. The laundry was washed with staff assistance. 12/10/2024 Implemented
6400.111(a)There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. At the time of the inspection, the basement did not have a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A fire extinguisher was purchased and placed in the basement of the home. 12/30/2024 Implemented
6400.165(c)Individual #1 is prescribed Buspirone Tab 10 mg, take 1 tablet by mouth daily three times a day for schizoaffective disorder. The medication was initially initialed as being administered on 12/3/24 at 8am to Individual #1 on the Medication Administration Record(MAR), and then noted on MAR as the mediation being missed dose on 12/3/24 at 8am as the agency discovered the error on 12/4 prior to the inspection that the medication remained in the blister pack. The medication is not being administered as prescribed. (repeat violation 12/8/23)A prescription medication shall be administered as prescribed.Agency nurse was contacted regarding the missed medication. Incident was entered into HCSIS (Incident Number 9529809). 12/05/2024 Implemented
6400.181(f)The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. Individual #1's Individual Support Plan (ISP) meeting was 10/22/24 and their annual assessment was sent to the team on 11/14/24.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Individual¿s skills assessment was sent to the team on 11/14/24. 12/30/2024 Implemented
6400.213(1)(i)Violation is for 213(1)(iii): Individual #1's Communication, primary language was not included in their record as this was left blank. A drop-down box for 213(1)(iii) is not available.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual¿s face sheet was updated in the individual¿s binder. 12/05/2024 Implemented
SIN-00235689 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Surfaces are not in good repair. The mini blinds in the living room behind the couch had three broken slats.Floors, walls, ceilings and other surfaces shall be in good repair. Broken blinds were removed from individual #1¿s bedroom and replaced with curtains on 12/16/23. 12/16/2023 Implemented
6400.71Emergency phone numbers were not located on or near the phone in Individual #1's bedroom.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 numbers were posted by each phone in the Nicholson home on 12/8/23. 12/08/2023 Implemented
6400.34(a)Individual #1 was informed of the individuals' rights, however the individual was informed late. Individual #1 moved into the home on 11/7/23 and was not informed of the Individuals' rights until 11/27/23.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.Individual #1 signed a new form regarding individual rights on 1/11/24. 01/11/2024 Implemented
6400.169(a)Staff #1 did not complete a department approved medication administration course including the renewal requirements. Staff #1 did not complete two medication administration observations in a 6-month period. Staff #1 completed one medication administration observation on 5/5/23 and should have completed a second my 11/5/23.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).Staff #1 was observed administering medications by a certified Medication Administration trainer on 1/9/24 according to the requirements for a missed observation. 01/09/2024 Implemented
SIN-00219542 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The storm door located on the back door of the home did not have a functioning handle or latch. Screens, windows and doors shall be in good repair. Individual in the home broke the door handle the evening before inspection. A new storm door was purchased and installed immediately after the inspection. 03/24/2023 Implemented
6400.81(k)(6)Individual #1 did not have a mirror in their bedroom.In bedrooms, each individual shall have the following: A mirror. Mirror was purchased immediately after inspection and installed in the individual's bedroom. 03/17/2023 Implemented
Article X.1007Eihab Human Services Pennsylvania is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 did not hold permanent residency in Pennsylvania for two consecutive years prior to beginning employment and an FBI criminal history record check was not completed.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.Human Resources requested finger printing to be completed by Staff #1. Staff provided FBI clearances from prior to hire with Eihab Human Services and also went for new FBI clearances on 04/03/2023 Implemented
SIN-00191677 Unannounced Monitoring 08/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Eihab is not keeping accurate financial records for Individual #3. Purchases and deposits are not being recorded properly and receipts for purchases are not being kept. July's financial ledger starts with a balance of $509.00. There are 3 blank entries for 7/8/2021, 7/18/2021 and 7/18/2021 with no purchase amounts. The next entry dated 7/20/2021 shows a purchase of $5.30 and a balance of $91.22. $409.48 is not accounted for on his financial ledger between these dates. There are 2 blank entries on 7/24/2021 with no purchase amounts and a balance of $124.55 ($200 was deposited on 7/23/2021). $160.11 is not accounted for on his financial ledger. The last blank entry is on 7/28/2021 with no purchase amount but a balance documented as $98.72. $14.39 is not accounted for on his financial ledger. There were also several receipts not accounted for on Individual #1's financial ledger. The following receipts were not logged on Individual #3's financial ledger for July: 7/3/2021: $11.44 (McDonalds); 7/4/2021: $10.70 (Tunkhannock Convenience); 7/6/2021: Amount unknown (Burger King); Date unknown: $5.30 (Burger King); Date unknown: $21.26 (Cigarette Outlet); 7/24/2021: $145.51 (Walmart); and 7/28/2021: $14.39 (Subway). There is also a notation in the section for receipts that 2 receipts were found in a drawer on 7/18/2021 that were not recorded in the ledger. These receipts are neither in the financial book nor does it specify how much money was spent for either transactions. Individual #3's bank statement shows a $83.00 purchase (Discount Tobacco) on 7/8/2021. This purchase is not documented on his ledger. Deposits are not being accurately recorded on Individual #3's financial ledger. $200 is the only deposit listed for the month of July. According to his bank statement, there was a $100 on 7/3/2021, a $500 deposit on 7/8/2021 and a $200 deposit on 7/23/2021.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Individual #3 financial records have been reconciliated and now reflect accurate totals. 08/26/2021 Implemented
6400.22(e)(3)Eihab is not keeping receipts for purchases greater than $15.00 for Individual #1. It was reported that Individual #3 made some large on-line purchases in July, but there are no receipts for these purchases. According to his bank statement, he made the following Ebay purchases: 7/7/2021: $20.66, $17.27, $22.25; and $313.38 on 7/9/2021. His bank statement also shows a $83.00 purchase (Discount Tobacco) on 7/8/2021 that there is no receipt for. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Individual #3 financial records have been reconciliated and now reflect accurate totals. 08/26/2021 Implemented
6400.64(e)The trash can in the kitchen had a lid on it, however it was broken and did not cover the trash can appropriately.Trash receptacles over 18 inches high shall have lids. This trash receptacle was replaced following this monitoring visit. 08/09/2021 Implemented
SIN-00190493 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(1)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the individual's name was not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name.This medication was added to the MAR for individual #2 on 7/17/21. 09/15/2021 Implemented
6400.166(a)(2)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Prescriber information was not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.This medication prescriber was added to the MAR for individual #2 on 7/17/21. 09/15/2021 Implemented
6400.166(a)(4)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Medication Name was not included on the Medication Administration Record.(Repeat Violation: 1/19/2021)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.This medication was added to the MAR on 7/17/21 09/15/2021 Implemented
6400.166(a)(6)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Dose Form was not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.This medications prescribed dosage form was added to the MAR on 7/17/21 09/15/2021 Implemented
6400.166(a)(7)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Dose of the Medication was not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.This medications prescribed dose was added to the MAR on 7/17/21 09/15/2021 Implemented
6400.166(a)(8)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Route of the Medication was not included on the Medication Administration Record. (Repeat Violations: 1/19/2021)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.This medications prescribed route of administration was added to the MAR on 7/17/21 09/15/2021 Implemented
6400.166(a)(9)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Frequency of Administration was not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.This medications frequency of administration was added to the MAR on 7/17/21 09/15/2021 Implemented
6400.166(a)(10)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Administration Times were not included on the Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.This medication was added to the MAR as a pro re nata on 7/17/21. 09/15/2021 Implemented
6400.166(a)(11)Individual #2 is prescribed Polyethylene Glycol 3350. MiraLAX Over the Counter (OTC). Dissolve 17gm in 8 ounces or water or juice and consume as needed. DX Constipation). At the time of the inspection, the Diagnosis/Purpose was not included on the Medication Administration Record (Repeat Violation 1/19/2021, 5/12/2021)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.This diagnosis for which this medication is prescribed was added to the MAR on 7/17/21. 09/15/2021 Implemented
SIN-00181626 Renewal 01/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The side of the wraparound deck was not cleared of snow from the previous night. This part of the deck can be used as a walkway to get from the front to the back of the house. Outside walkways shall be free from ice, snow, obstructions and other hazards. During the review, it was noted that although the staff ensure the front door and rear door was not obstructed with snow, the walkway/side deck was not fully cleared of snow. The walkway and side deck was cleared on the day of virtual survey. Staff and Management was trained that when cleaning and clearing snow to ensure that outside walkways are free from ice, snow, obstruction and other hazards; to include the entire walkway and side deck fully. During inclement weather, managers will follow up and remind staff to during the shift to clear all outside walkways from ice, snow, obstructions to prevent accumulation that will cause any hazard. This will be reviewed with staff and management by March 15, 2021. 03/15/2021 Implemented
6400.112(d)There were 3 failed fire drills this year. Individual #2 refused to evacuate for the fire drills held on 6/29/2020, 10/8/2020 and 10/9/2020. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Since the time of the survey, the behavior specialist has evaluated Individual #2 for a behavioral modification plan for fire drill participation for his safety. The Vice President has developed a Fire Drill Report Review Procedure which includes a Shared Fire Drill Annual Calendar amongst management and administration. On the shared calendar, drills will be scheduled to ensure various conditions with indicate alternate exits to be used. This shared calendar will be reviewed on a daily basis by the Program Specialist to ensure and verify that all scheduled drills have been completed. In addition, staff will upload the documented fire drill report for the Management and Program Specialist to review the drill report within 24-72 hours. Management and the Program Specialist will review the drill report to ensure that the scheduled drill was successful and documentation was complete and accurate. If a drill was not successful due to an individual refusing to participate in a drill, the behavioral specialist will be notified and a repeated drill within 24 hours will be repeated. If the repeated is unsuccessful again due to refusal the team will be immediately notified to determine a plan of action for his safety. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. This procedure will be monitored on a daily basis by the Program Specialist for oversight and ensure that all drill reports completed as indicated. The Quality Assurance Department will be conducting quarterly reviews of all fire drills to ensure this procedure is followed and fire drills procedures are in compliance. 03/15/2021 Implemented
SIN-00162272 Renewal 09/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill was held on 04-29-18, then not again until 04-28-19.A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill occurred on 4.29.18 and occurred again on 4.28.19. Unannounced sleep drills will be conducted from 11pm and 6am by the area Program Specialist and the Program Director to ensure drills are being completed in accordance to regulation. Staff will be retrained annually on the regulations for sleep drills and fire safety. Implemented
6400.143(a)Individual #2 had multiple refusals of meds and no training was documented anywhere.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. Individual #2 refused medications multiple times and no documentation of training was provided. Behavior S will develop a desensitization plan for this individual. All staff will be trained on the plan. The Behavior Specialist will continue to work with this individual to positively reinforce medication compliance. 11/01/2019 Implemented
SIN-00100815 Renewal 11/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no thermometer 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. The thermometer was replaced. To prevent this from happening in the future, the first aid box check for necessary items will be added to the monthly fire drill documentation. 12/23/2016 Implemented
6400.141(c)(10)This section was left blank on Individual #3's physical exam dated 10/7/2016.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. On 11/28/2016, the individual returned to the doctor and the PCP completed the physical in its entirety. To prevent this from happening in the future, all staff will be retrained on medical appointment documentation requirements. Medical policy updated and clarified. 12/23/2016 Implemented
6400.141(c)(14)This section was left blank on Individual #3's physical exam dated 10/7/2016.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 11/28/2016, the individual returned to the doctor and the PCP completed the physical in its entirety. To prevent this from happening in the future, all staff will be retrained on medical appointment documentation requirements. medical Visit policy clarified and updated. 12/23/2016 Implemented
SIN-00124569 Renewal 11/14/2017 Compliant - Finalized