Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00276437 Renewal 09/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no drill for December 2024 found during inspection. An unannounced fire drill shall be held at least once a month. As the document is missing, please see our plan to maintain compliance prospectively, immediately below. 11/10/2025 Implemented
6400.181(a)Assessment for Individual 1 was completed 07/07/2025 which is more than 380 days after the previous assessment dated 06/12/2024. 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. Embolden acknowledges that the assessment was late and will ensure that assessments are completed timely. 11/10/2025 Implemented
SIN-00263802 Unannounced Monitoring 04/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34Inspectors were unable to access the program after waiting several hours and had difficulty reaching administrative staff in order to be granted access to the location. Several phone calls placed to the office phone went unanswered and no administrative staff were available to let inspectors into the home. After additional phone calls, the provider arranged for the inspector to come back the next day (April 4, 2025).The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.Embolden Management shall provide ODP with all contact information of key personnel to ensure ODP's timely access to Embolden Service Locations in the event that the Service Location is vacant. Due to the small size of the Embolden Management Team, Embolden will also affix locked boxes with spare keys to homes. 09/11/2025 Implemented
6400.72(a)The kitchen sliding door to the outside was open with no screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The kitchen sliding door screen was replaced on 4/11/25. The image of the fixed screen door was sent to the inspector via email on 4/16/25 04/11/2025 Implemented
6400.72(a)One of the chairs of the kitchen table was not sturdy and needs to be repaired or replaced.Windows, including windows in doors, shall be securely screened when windows or doors are open. The dining room chair was removed on 4/3/25 04/03/2025 Implemented
6400.112(c)The fire drills on 05/20/24, 6/11/24, 07/19/24, and 09/04/24 did not address if there were any problems encountered during the drill.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. Regarding the May, June, July and September (2024) fire drill forms, all exit routes and equipment were check marked as operational on the documentation (see Exits & Equipment Operational section). Any exit routes or equipment that is not in operation will also be documented on the fire drill form (if applicable) and addressed appropriately. These forms were addressed and resolved on the 9/12/24 inspection summary and POC. There were no errors on the forms because no equipment problems were documented on the forms. Copies of the fire drill forms were sent to the inspector via email on 4/16/2025. 04/03/2025 Implemented
6400.166(a)(11)Individual #2's medication Fluticasone did not have diagnosis or purpose for the medication on the MAR.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.The Fluticasone entry in the MAR has been amended to include the diagnosis and purpose for the medication. 04/03/2025 Implemented
6400.166(a)(12)Individual #2's medication Bupropion had the time listed as noon on the blister pack, however the medication had the time of 2 PM on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.The following information is documented on each blister pack: Bupropion HCL 150MG XR. Round, purple:SG175. Qty 14. Ref. 0. 1 tab first thing in the AM & another around 2pm. The Medication Administration Record (MAR) states the same order reflected on the blister packs. There is no instruction to administer the medication at noon on any blister pack. There were no errors on the MAR. The instructions documented on the MAR matched the Rx instructions documented on the blister packs. An image of one of the blister packs was sent to the inspector via email on 4/14/2025. 04/03/2025 Implemented
SIN-00252332 Renewal 09/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drills for December (2023), January, May, June, July September (2024) do not indicate if there were any problems encountered during the drill. The March 2024 fire drill did not indicate the exit used.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. Regarding the March 2024 fire drill record, we will ensure that fire drill records going forward will document the exit route used. Regarding the December (2023), January, May, June, July September (2024), all exit routes and equipment were check marked as operational on the documentation (see Exits & Equipment Operational section). Any exit routes or equipment that is not in operation will also be documented on the fire drill form (if applicable) and addressed appropriately. 10/11/2024 Implemented
6400.141(c)(14)Individual #1's most recent physical exam dated 4/11/24 did not contain Information Pertinent to diagnosis incase of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's PCP wrote a letter providing key pieces of information pertinent to individual #1's diagnosis and treatment which can be used in case of an emergency. This letter will be kept in individual #1's record and shared with appropriate parties in emergency situations. A copy of the letter was emailed to licensing personnel on 9/27/24. 09/24/2024 Implemented
6400.181(e)(1)The annual assessment for Individual #1 does not include complete information pertaining to adjustment over the last 365 days. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The 2023 and 2024 Annual Assessments summarize that there has been no change in the functional strengths, needs and preferences of individual #1. Any significant changes will be documented in future assessments. A copy of both assessments will be sent to licensing by 10/18/24. 10/18/2024 Implemented
6400.217There was no consent documentation present in the file of individual #1.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Individual #1 signed the Embolden Medical Release of Information form on 11/13/21. Embolden has not disclosed any information to outside parties. A copy of the consent form was emailed to licensing personnel on 9/27/24. A copy of the completed Photographic, Videotape, and Audiotape Information Release form will be sent to licensing by 10/18/24. 10/18/2024 Implemented
6400.34(a)Individual Rights signed by individual #1 dated 7/1/24 are not complete and do not include the section pertaining to locks on doors.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 the amended Rights Statement on 9/13/24 which includes the statement concerning the locks. A copy of the amended statement was sent to licensing on 9/27/24. 09/27/2024 Implemented
6400.181(f)There was no documentation of when the annual assessment dated 6/12/24 for individual #1 was sent to the team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A copy of an email dated 5/30/24 was sent to licensing personnel on 9/27/24. The email informed the staff on when the current assessment would be made available for review. A copy of the assessment was also made available to the Support Coordinator. Individual #1's ISP meeting is due to occur on November 11, 2024. 09/27/2024 Implemented
SIN-00244468 Unannounced Monitoring 05/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The stovetop and inside of the oven is sticky with grease and grime. Staff stated that self-cleaning oven does not work.Clean and sanitary conditions shall be maintained in the home. sStovetop was cleaned with a grease remover cleaner. 05/13/2024 Implemented
6400.76(a)Dining room table unstable / shaky on all four legs. Need to be replaced or repaired. Furniture and equipment shall be nonhazardous, clean and sturdy. Dining table legs have been fixed. 05/20/2024 Implemented
6400.144PRN medication for individual #1, Acetaminophen (generic for Tylenol) 500 MG. Take 2 tablets every 6 hours as needed. Expiration date was 2/7/2024 Container was empty / expired and still in med box.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Empty Acetaminophen bottle was removed and disposed of. 05/13/2024 Implemented
SIN-00243389 Unannounced Monitoring 04/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The master bathroom on the second floor does not have a window and the fan that would typically provide ventilation to the room was not functional.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Master bathroom mechanical vent has been fixed. 05/04/2024 Implemented
SIN-00234443 Unannounced Monitoring 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The refrigerator, freezer and oven need to be cleaned, as there is a moderate grime and/or grease buildup. The kitchen trash can lid has food residue on it.Clean and sanitary conditions shall be maintained in the home. The refrigerator, freezer and oven were cleaned. 12/01/2023 Implemented
6400.67(a)The first-floor bathroom vanity drawer is missing a doorknob.Floors, walls, ceilings and other surfaces shall be in good repair. New doorknobs in the bathroom vanity drawer were installed. 12/01/2023 Implemented
6400.67(b)The curtain rod leading to the back patio is loose and not securely affixed to the wall. Floors, walls, ceilings and other surfaces shall be free of hazards.The curtain rod leading to the back patio was secured to the wall. 12/01/2023 Implemented
6400.163(h)Individual#1's prescribed medication Flovent 220 mg with instructions to inhale 1 puff by mouth twice daily, had a manufacturers expiration date of 10/2023. There were two of these expired medications. There was a non-expired medication of same name present in home for use which had not yet been opened.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Flovent 220mg inhalers with the expiration date of 10/2023 were found to be empty and discarded from the medication box. 12/01/2023 Implemented
6400.166(a)(4)Individual#1 had medication cetirizine (Zyrtec) hcl 10 mg with instructions to take one tablet by mouth daily present in home, but not listed 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 medication.Centirizine (zyrtec) hcl 10mg was entered on the MARs upon receiving confirmation from the prescriber that the pharmacy dispensed the correct medication. 12/01/2023 Implemented
SIN-00226222 Unannounced Monitoring 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)72b 2 The window on the far side of the bedroom from Individual #1's bed has a broken frame. The frame across the midpoint of the window is detached at one side; the loose side falls down into the window. The sliding closet door in Individual #2's room is partially out of its track, making it difficult to open and close the closet door. Screens, windows and doors shall be in good repair. The frame across the midpoint of the window that was detached at one side has been fixed. 09/15/2023 Implemented
6400.73(a)The railing for the stairs leading to the second floor is detached from the wall at its bottom. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The railing for the stairs leading to the second floor that was detached from the wall at its bottom was fixed on 06/17/2023. 06/17/2023 Implemented
6400.111(e)The second-floor fire extinguisher is not easily accessible. It is located at the back of Individual #2's bedroom closet. To access it requires opening two doors, one of which is able to be locked. A fire extinguisher shall be accessible to staff persons and individuals. The second-floor fire extinguisher has been moved and fixed at the top of the stairs. 06/17/2023 Implemented
6400.144Per agency documentation provided during this inspection, Individual #2 blood sugar screenings were discontinued in July 2022. Blood sugar testing continued beyond this date, with blood sugar logs, diabetic testing supplies, and a blood sugar meter having been observed in their medication kit and house documentation during the agency's previous inspection in February 2023Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The primary care physician was contacted and written orders concerning the discontinuation of blood sugar testing was issued on 3/28/2023. Program Specialist shall ensure that copies of all orders and kept in the individual¿s record. 09/15/2023 Implemented
SIN-00219670 Unannounced Monitoring 02/15/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff 6 - no criminal history record check was found in the personnel record.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. This violation is not entirely accurate: staff person had the child abuse fingerprinting and PA state police background checks in their personnel files. Staff completed FBI criminal history fingerprinting on 2/28/23 03/31/2023 Not Accepted
6400.43(b)(1)Per the site manager, Embolden's COVID policy states that an individual is supposed to quarantine following a positive COVID-19 test result. Individual 3 was not quarantining, as this individual was observed in common areas of the home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Individual three was quarantining in the privacy and comfort of their own home. Embolden follows CDC guidelines for the 5-day home quarantine period, but does not and cannot force any individual to self quarantine in their bedrooms. All the individuals in the home were quarantined for 5-days and tested-- each tested negative-- and their respective teams were informed of the positive COVID outbreak prior to the quarantine period. Embolden did not allow visitations during the quarantine period. 03/31/2023 Not Accepted
6400.64(a)The oven and stove top had a large amount of grease build-up that needs to be cleaned.Clean and sanitary conditions shall be maintained in the home. Oven and stove top have been cleaned. 03/31/2023 Not Accepted
6400.67(a)The miniblinds in Individual 2's ensuite bathroom were missing seven slats.Floors, walls, ceilings and other surfaces shall be in good repair. Blinds were replaced. 03/31/2023 Not Accepted
6400.144Pharmaceutical services are not being fully rendered for Individual 2. Their Lokelma medication indicates it is to be administered every other day; its administration has been signed for every day in February on the MAR. The medication is also stored without its pharmacy label. As such, it cannot be determined that the medication is being administered according to prescribed orders. The individual's PRN albuterol inhaler was not stored with their other medications and also did not have a pharmacy label; it was in the individual's bedroom. Their ISP does not indicate that they self-medicate. The individual's blood sugar readings are not logged consistently, and when logged in daily notes, are sometimes logged incorrectly, such as on 2/3/23 when the meter read 185 but was recorded in a daily note as 182, and on 2/4/23 when the meter read 142 but was recorded as 140.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Prescriber was contacted to provide clear instructions concerning the administration of Lokelma -- essentially to specify the days it should be administered-- as the current instruction "every other day" is unclear and is open to misinterpretation. Pharmacy has yet to receive the new orders for re-labeling. The PRN Abuterol inhaler is stored in its original container and kept with the other medications. Staff persons have been re-instructed on reading the blood sugar meter accurately. 03/31/2023 Not Accepted
6400.151(a)Staff 12 - the last physical found in the record is for 9/13/2020. The next physical was due in September of 2022 and was not found in the record. 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. Physical was included in the staff record sent via email on March 7, 2023. 03/31/2023 Not Accepted
6400.151(c)(2)Staff 12 - the last TB test was completed on 9/13/2020 and the record does not include a test being performed in September of 2022. 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. TB was included in the staff record sent via email on March 7, 2023. 03/31/2023 Not Accepted
6400.151(c)(3)Staff 12 - there was no statement indicating that the staff member is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff person signed the ECA Health Attestation form verifying that they are free of communicable diseases, information was sent via email on March 7 2023 03/31/2023 Not Accepted
6400.32(d)Individual 3 tested positive for COVID-19 on February 14, 2023, and was not quarantining in a separate section of the home that he shares with his two roommates: Individual 2 and Individual 4. During the physical site inspection, Individual 3 was observed in the shared living room area and staff reported that he also ate breakfast this morning in this shared space. Individual 3 also shares a bathroom with Individual 4. The house manager states that neither Individual 2 or Individual 4 have been tested for COVID-19 since Individual 3's positive test.An individual shall be treated with dignity and respect.Individual three was quarantining in the privacy and comfort of their own home. Embolden follows CDC guidelines for the 5-day home quarantine period, but does not and cannot force any individual to self quarantine in their bedrooms. All the individuals in the home were quarantined for 5-days and tested-- each tested negative-- and their respective teams were informed of the positive COVID outbreak prior to the quarantine period. Embolden did not allow visitations during the quarantine period. 03/31/2023 Not Accepted
6400.166(a)(13)Individual 4's Celecoxib medication is to be administered every morning and evening for mild pain per their MAR. Staff has only signed for the morning administrations throughout the month of February; all evening administrations were not signed for in the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Individual 4's medications are packaged together in one singular blister pack with AM medications in one column and the PM medications in a separate Colum. Medication was administered, staff persons failed to initial the PM medications, but medication counts reflect that they were administered. Going forward supervisory personnel shall check MARs at least weekly to ensure that staff initial every administration of each medication. 03/31/2023 Not Accepted
6400.169(d)Staff 12 - there was no documentation found for the 12/2022 MAR review as required. The handwashing checklist was not completed in 2022.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.As requested, MAR review records concerning staff person 23 was sent via email March 7 2023. Ensure that all active personnel records are kept separately from inactive personnel records. 03/31/2023 Not Accepted
SIN-00215218 Unannounced Monitoring 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The Shower Molding in the main level bathroom was missing trim leaving parts of the wall exposed to moisture.Floors, walls, ceilings and other surfaces shall be in good repair. Shower molding has been repaired 01/13/2023 Implemented
6400.68(b)The water on the first floor bathroom sink and shower measured at approximately 161.5 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water heater has been checked and water temperature does not exceed 120 degrees F (roughly 118) 12/06/2022 Implemented
6400.76(a)The Table in the kitchen wobbled to the touch and was not sturdy when leaning. Furniture and equipment shall be nonhazardous, clean and sturdy. Kitchen table has been fixed to prevent it from wobbling 12/06/2022 Implemented
6400.101The Basement door had a lock from the inside of the basement door that would prevent immediate escape of the room in the event of an emergency. The latch was on the main level side of the door and not on the basement side.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Basement door lock has been switched to the opposite side 11/30/2022 Implemented
6400.32(r)The bedroom door locks used to lock the individual rooms were not unique and did not provide adequate privacy. They can be unlocked with use of a generic coin to turn.An individual has the right to lock the individual's bedroom door.Each bedroom door locks have been changed so that each as a unique key. 11/30/2022 Implemented
SIN-00247173 Unannounced Monitoring 07/02/2024 Compliant - Finalized
SIN-00246610 Unannounced Monitoring 06/20/2024 Compliant - Finalized