Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253282 Renewal 09/26/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency has not adequately completed Self Assessments for all residences. Provided documentation was identical for all properties including the vacant homes which included responses for health related individual file elements.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self-assessments for the vacant sites have been corrected. The corrected forms will be emailed to the inspector. 10/31/2024 Not Implemented
6400.21(a)The agency has multiple staff members hired since last renewal whose Criminal History background checks were not completed within five working days after date of hire: Staff Member 1 - Hired: 3/4/24, Date of Request: 3/20/24; Staff Member 2 - Hired: 10/30/23, Date of Request: 3/14/24; Staff Member 3 - Hired: 10/16/23, Date of Request: 10/29/23; Staff Member 4 - Hired: 10/16/23, Date of Request: 10/26/23; Staff Member 5 - Hired: 10/16/23, Date of Request: 10/29/23; Staff Member 6 - Hired: 11/1/23, Date of Request: 11/11/23; Staff Member 7 - Hired: 1/22/24, Date of Request: 1/28/24; Staff Member 8 - Hired: 11/1/23, Date of Request: 11/11/23.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 onboarding process has been updated to conduct the criminal history background check at the beginning of the onboarding process. The updated procedures will be emailed to the inspector. 10/31/2024 Not Implemented
6400.43(b)(1)The agency provides the Residential Habilitation HCBS Waiver service. One of the requirements to provide this service is that if criminal history clearance results identify a criminal record, providers must make a case-by-case decision about whether to hire the person that includes consideration of the following factors: the nature of the crime; facts surrounding the conviction; time elapsed since the conviction; the evidence of the individual's rehabilitation; and the nature and requirements of the job. There is no documentation to demonstrate internal review based on the returned criminal records for Staff members 6, 9, 10, and 11 at their times of hire.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. The CEO will review the criminal history background checks for staff that have a record. A review for will be completed for all staff that have a record and emailed to the inspector. 11/25/2024 Not Implemented
6400.112(d)The fire drill completed on 5/18/24 exceeded 2.5 minutes. 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. -Provider retrieved fire drills from the service location in question. - Provider reviewed fire drill procedures with all staff during the bi-weekly conference call to ensure understanding of their roles and responsibilities. 10/25/2024 Not Implemented
6400.32(d)The agency has completed an excessive amount of overnight fire drills at this property causing frequent interruptions to the Individual's sleep. Overnight drills were completed on 11/15/23; 11/28/23; 1/31/24; 2/27/24; 4/10/24; 5/31/24; and 7/31/24An individual shall be treated with dignity and respect.Provider developed a monthly fire drill schedule that includes dates, times, and specific objectives for each drill to prevent an excessive amount of fire drills to be completed on 1 shift. 10/25/2024 Not Implemented
SIN-00172477 Renewal 03/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dryer had lint build up the size of a golf ball in the lint trap. Furniture and equipment shall be nonhazardous, clean and sturdy. A sign will be posted near the Laundry equipment to alert staff to remove lint from dryer filter after each use. ( Stop SIGN/check dryer lint) 04/01/2020 Implemented
6400.46(a)Initial fire safety was not completed prior to working with individuals upon date of hire on 1/18/20 for staff 1. 3/8/20 was the only training found in record at the time of review.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements Person Centered and Incident Management 06/30/2020 Implemented
6400.50(a)Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, were not kept for staff 1. Trainings were included in record were not required orientation documents.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements. In addition, the consultant will be reviewing all of Jami Residence training records to identify additional non compliances staff training. Retrain staff on required trainings if the Jami Residence staff is discovered to be out of compliance. 06/30/2020 Implemented
6400.51(a)(3)Orientation training was not fully completed and documented for staff 1 upon 1/18/20 date of hire.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.The agency has hired a training consultant, who will be responsible for providing all of Jami Residence staff training in accordance with OPD trainings requirements and will work to bring all of the organization employees training hours and requirements into compliance with ODP training regulatory requirements Person Centered and Incident Management i 06/30/2020 Implemented
SIN-00211729 Renewal 09/14/2022 Compliant - Finalized