Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274033 Renewal 09/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)On 9/10/2025 at 11:27 AM, a blue binder, entitled, "[Individual #1]: Doc. of Agitation, Anxiety, Stimming, and Targeting," which included Individual #1's personal information documented on behavioral charts dated from 1/3/2020 to 8/24/2021 was unlocked and accessible inside the closet in the kitchen on the first floor of the home. An individual's records shall be kept locked when unattended. On 9/10/25 a memo was sent to Hyde Park Staff informing them that A Request for Maintenance form has been completed to change the knobs on the closet be changed to knobs that utilize a key to unlock and lock the knob. New knobs that lock with keys were installed on 9/11/2025. The binder has been sent to the administrative office for archiving since it was from 2020/2021 and no longer needed at the home. 09/11/2025 Implemented
6400.195(a)Individual #1's Service Plan, last updated 8/27/25, states the following regarding their bedroom: "[Individual #1] is unable to have a mirror due to the possibility of breaking it."; "[Individual #1's] dresser is kept in a spare bedroom due to [them] taking out/ throwing the drawers"; and "[Individual #1] does not have clothes hanging in [their] closet due to [them] taking/ throwing [the] [clothes] out." Individual #1's current assessment, completed on 4/17/25, contains no reference to or language regarding these bedroom modifications. At 11:35 AM on 9/10/25, although Individual #1's clothes were hanging in their bedroom closet, Individual #1's bedroom did not have a mirror and dresser or chest of drawers. Individual #1 does not have a restrictive procedure plan that has been approved by the human right teams for these limitations.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.On 9/16/25 KVOU Program Specialist reread, and signed off acknowledging this, DHS ODP RCG 55 PA Code Chapter 6400 3/15/23 edition pages 1-18, 37-52, 107-128. On 9/25/25 KVOU Program Specialist updated his assessment information, typed out the changes needed in his ISP and emailed the changes and clarification to this person's Support Coordinator. The information contained in this violation summary description was/is historical in nature. The individual's dresser has been moved back into his bedroom (verified by the Program Specialist). When asked, he continues to choose not to have a mirror in his bedroom and his team continues to respect his choice. This is not for behavioral reasons, he is blind and has no use for a mirror. 09/25/2025 Implemented
SIN-00161207 Renewal 08/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a tuberculin skin testing completed on 11/18/15 and then again 3/30/18.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The agency created a new position entitled Medical Compliance Coordinator in August 2018. The job qualifications included a Licensed Practical Nurse (LPN) requirement. One of the main job responsibilities of this position was ensuring all annual medical licensing requirements under 6400.141 and 6400.142 were completed in a timely manner for all individuals. In addition, a procedure was created entitled "Yearly Medical Appointment and Medical Information Chart Audit". This procedure included the Program Specialist conducting a quarterly audit of the MCC's documentation to ensure compliance with 6400.141 and 142. The MCC is also required to follow the "Procedure for Tracking Medical Compliance Appointments which includes tracking annual physicals including vision and hearing, annual dental, 90 day med checks, prostate, mammogram, pap test, TB test every 2 years and D-TAP every 10 years for every individual. Our current MCC, Kathy Otto (LPN) received training of all medical compliance regulations and the above procedures during her initial training on 02/26/2019. 08/27/2019 Implemented
SIN-00077927 Renewal 09/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment did not include a completion date; therefore, compliance was unable to be measured.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. A procedure will be written and staff trained that the Executive Director will disburse the current Licensing Inspection Instrument Scoresheet Facility Chapter 6400 Community Homes annually on or before January 19th which is 6 months prior to the expiration date of the Certificate of Compliance. The inspection instruments will be due from the following positions on or before March 31st: Residential Program Supervisor and Program Specialist. The inspection instrument will be due from the Administrative Officer who completes the Staffing section including the training requirements in Regulation 46 and Staff Health including physicals on or before April 15th which is approximately 3 months prior to the expiration of the Certificate of Compliance. The Executive Director will ensure the deadlines are met and then compile the data into one scoresheet for each residential home on or before April 18th which is 3 months prior to the expiration date. 10/04/2015 Implemented
SIN-00252276 Renewal 09/25/2024 Compliant - Finalized
SIN-00232241 Renewal 10/03/2023 Compliant - Finalized
SIN-00213316 Renewal 10/19/2022 Compliant - Finalized
SIN-00196569 Renewal 11/22/2021 Compliant - Finalized
SIN-00180241 Renewal 12/17/2020 Compliant - Finalized
SIN-00140656 Renewal 08/28/2018 Compliant - Finalized
SIN-00120684 Renewal 08/30/2017 Compliant - Finalized
SIN-00100978 Renewal 09/01/2016 Compliant - Finalized
SIN-00062975 Renewal 09/05/2014 Compliant - Finalized
SIN-00051313 Renewal 06/27/2013 Compliant - Finalized