Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00277599 Renewal 11/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(h)On 11/5/25, at approximately 11:40 AM, Individual #2's bedroom window was completely covered in an opaque film that prevented a view of the outside.Each bedroom shall have at least one exterior window that permits a view of the outside. In accordance with 55 PA Code Chapter 6400.81(h) each bedroom shall have at least one exterior window that permits a view of the outside. 12/19/2025 Implemented
6400.171On 11/5/25, at approximately 11:30 AM, there was a open and unprotected quart sized container of Friendly farms plain yogurt with a best by date of 10/20/25. The yogurt had a noxious smell and was spoiled.Food shall be protected from contamination while being stored, prepared, transported and served. In accordance with 55 PA Code Chapter 6400.171 food shall be protected from contamination while being stored, prepared, transported and served. 12/19/2025 Implemented
6400.216(a)On 11/5/25, at approximately 11:30 AM, Protected Health Information for Individual #1 and Individual #2 was posted in the kitchen on the refrigerator. This included scheduled medical appointments and healthcare provider information, as well as dates of birth for both individual and related personal care needs. An individual's records shall be kept locked when unattended. In accordance with 55 PA Code 6400.216(a) an individual's records shall be kept locked while unattended. 12/19/2025 Implemented
6400.166(a)(11)On 11/5/25 Individual #1's November Medication Administration Record (MAR) did not include a diagnosis or purpose for the following medications: Carbamazepine 300 MG ER and Vitamin D3 2000 Unit Tablet.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.In accordance with 55 PA Code Chapter 6400.166(a)(11) a medication record shall be kept for each individual which includes the diagnosis or purpose of the medication, including PRN. 12/29/2025 Implemented
6400.166(b)On 11/5/25 Individual #1's November Medication Administration Record (MAR) was not initialed or signed that medications were administered on 11/2/25 at 8 PM for the following medications: Carbamazepine 100 MG Capsule, Clonazepam 2 MG tablet, and Sertraline 100 MG tablet. A review of the available medications revealed that this was a documentation error and the medications had been administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.In accordance with 55 PA Code 6400. 166 (b) a medication record shall be kept for each individual for whom a prescription medication is administered which includes the name and initials of the person administering the medication. 12/19/2025 Implemented
SIN-00258114 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home did not complete a self-assessment of the home. The documents provided during the inspection were not dated, did not contain the address of the home, and most of the regulations were left blank.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. In accordance with 55 PA Code Chapter 6400.15 (a) 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 (10.7.25) of the agency's certificate of compliance to measure and record compliance with this chapter. 01/13/2025 Implemented
SIN-00234832 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On 11/15/2023, staff interviews and financial ledgers revealed that Individual #1 and Individual #2 are being required to provide the cleaning and laundry supplies for the home from their personal funds.Individual funds and property shall be used for the individual's benefit. On 12/14/2023 individual 1 and 2 was reimbursed for supplies and laundry. The agency representative responsible for making this correction was (site supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collected and not just room. The agency representative that was responsible for the change was supervisor (supervisor). The agency representative will monitor the individual¿s funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. 12/14/2023 Implemented
6400.62(a)At 11:04 AM on 11/15/23, the lock on the cabinet doors underneath the kitchen sink of the home containing poisonous substances was observed not fully engaged, allowing space for the individuals to access them. Individual #1 is not assessed to be safe with poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. On 11/17/2023 a metal storage cabinet was purchased and delivered on 11/24/2023. The poisonous material was placed and locked in the storage cabinet by agency representative. The site supervisor will monitor if the poisonous material is being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. 11/24/2023 Implemented
6400.101On 11/15/23, there was a sliding chain latch-lock found on the front exit door of the home, posing a possible entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 12/6/2023 the maintenance man removed all chain locks from the door. Leasing office was informed that those type of locks cannot be used in the future. On 12/07/2023 the Program Specialist check all locations to ensure locks were removed. The site supervisor will monitor locks on lead checklist monthly to ensure compliance is being met, Program Specialist will monitor lead checklist monthly and site location quarterly to ensure compliance is being met for 1 year. The CEO trained the Program Specialist on appropriate lock systems and when and how they should be used. 12/07/2023 Implemented
6400.112(c)The written fire drill record provided from 12/7/22 to 10/10/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. On 11/21/2023 the agency representative (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drills and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drill performed. 11/21/2023 CEO trained Program Specialist and Supervisors on updated Fire Evacuation Record. 11/21/2023 Implemented
6400.216(a)At 11:20 AM on 11/15/23, binders containing personal records and documents related to Individual #1 and Individual #2, including but not limited to their assessment, individual plan, physical and dental examinations, were discovered on the floor of the dining room. An individual's records shall be kept locked when unattended. On 11/17/2023 the agency purchased a file cabinet with a locking system to store binders appropriately. On 11/20/2023 the binders were placed in the file cabinet by site supervisor to be stored appropriately. The site supervisor will monitor if the binders are being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. 11/20/2023 Implemented
6400.24On 11/15/2023, staff interviews and financial ledgers revealed that Individual #1 and Individual #2 are being required to provide the cleaning and laundry supplies for the home from their personal funds. Chapter 6100.684(d)VII requires that laundering of towels, bedding, and individual clothing be provided as part of room and board.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.On 12/14/2023 individual 1 and 2 was reimbursed for supplies and laundry. The agency representative responsible for making this correction was (site supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collected and not just room. The agency representative that was responsible for the change was supervisor (supervisor). The agency representative Joanne Walker will monitor the individual¿s funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. 12/14/2023 Implemented
SIN-00181824 Renewal 01/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not fully complete the self-assessment, dated 3/1/20, to measure and record compliance with each regulation for Title 55 Pa. Code Chapter 6400. The sections, to record if each regulation was either compliant, a violation, not applicable or not measured, were left blank.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. On January 29, 2021, (Program Specialist) complete the self assessment dated 3/1/20. Program Specialist will make sure that a self-assessment for each site is completed 3-6 months prior to on site inspection. CEO will audit assessment to assure the assessment is complete and all correction are made to assure compliance and assure that the same violation do not reoccur in the future. The POC will be implemented as of February 1, 2021. Upon receipt of certificate of compliance, the CEO or designee shall develop and implement a tracking system to ensure the self-assessment is completed timely. Prior to 3 months of the expiration date of the current certificate of compliance the CEO shall audit all completed self-assessment to ensure completion, timely. Documentation of audits shall be kept. [On 2/22/21, copies of the completed self-assessment and "physical site checklist", signed by the PS on 1/31/21 and CEO on 2/1/21 was provided to the Department. (AES,HSLS on 2/23/21)] 01/29/2021 Implemented
6400.81(k)(6)Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. On January 29, 2021, (Program Specialist) purchased and placed mirror in individual's bedroom. The Program Specialist will audit all bedrooms to assure that all items listed in 6400.81 to ensure compliance is being met. The POC will be implemented immediately to assure compliance and make sure the same violation will not occur again. Within 30 days of receipt of the plan of correction the Program specialist will train all staff person as to the required items in bedrooms as per 6400.81 and monitor and replace as needed. Documentation of trainings shall be kept. 01/29/2021 Implemented
6400.151(a)Program Specialist #1 had a physical examination completed on 9/6/18 and then again on 10/23/2020. 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 agency do not feel this was a violation due to the current pandemic and issues with scheduling. The Program Specialist had physical 10/23/2020. On January 22,2021 the medical provider who preformed the physical provided a letter stating why the physical was late due to covid-19. The agency will provide letter with supporting documents. 01/22/2021 Implemented
SIN-00162134 Renewal 09/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination completed 2/12/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination completed 5/28/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On September 17, 2019, Joanne Walker (Program Specialist), spoke with JJ individual #2 PCP requesting him to indicate any medical information pertinent to diagnosis and treatment in case of an emergency. On September 17, 2019 Joanne Walker faxed the most recent physical form to PCP office to be completed by PCP. On September 18 , 2019 Joanne Walker (Program specialist), spoke with CD's individuals #1 nurse requesting her to indicate any medical information pertinent to diagnosis and treatment in case of an emergency. On September 3, 2019 the CEO updated the agency physician medical form to reflect the requested information (that all physical's performed should indicate any medical information pertinent to diagnosis and treatment in case of emergency. Joanne Walker (program specialist) will check all physical form and document the dates the forms were completed. If Joanne finds any forms that need to be corrected she will contact PCP to get issued corrected within 30 days to remain in compliance with the chapter and to assure the same violation do not occur again. Upon completion and receipt of documentation of individual #1, the program specialist shall review to ensure all required information is completed and there are not any required areas left blank. Immediately. the CEO shall educate the program specialist and trained staff person shall review all individuals completed physical examination to ensure all required information is included and there are not any areas of required information left blank. The CEO will audit physical within 30 days of completion to make sure all pertinent information is completed. Documentation will be kept. [Individual #1's physical examination was update to include "no" for medical information pertinent to diagnosis and treatment in case of an emergency. (AES,HSLS on 9/24/19)] 09/17/2019 Implemented
SIN-00215237 Renewal 11/22/2022 Compliant - Finalized
SIN-00197320 Renewal 12/07/2021 Compliant - Finalized