Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00284851 Renewal 01/22/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window in the spare bedroom had a broken screen. Screens, windows and doors shall be in good repair. WHO: Administrative staff WHAT: Individual window above the kitchen sink had a broken screen. WHEN and HOW · Immediate repair of the damaged window screen was completed. Similar violation was identified at 3320 Mary st Apt 2 and resolved · Target dates: 1/26/26 · Specific dates:1/29/26 A plan to prevent future occurrences Administrative staff will conduct regular inspections, promptly repairing any damages. also require lead staff members to conduct weekly window screens inspection. 01/29/2026 Implemented
6400.141(c)(10)Physical forms should be completed accurately and in their entirety. Individual 4's March 25, 2025 physical did not indicate being free of communicable disease status as Yes or No albeit the physical dated May 2, 2024 indicated Yes to being free of them.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. WHO: Program specialist WHAT: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. WHEN and HOW · The individual physical form was returned the doctor's office for proper completion There is no other violation · Target dates:1/22/26 · Specific dates:1/27/26 A plan to prevent future occurrences · After each annual physical appointment, The Program Specialist will review all forms during presented during the physical examination visit. The Program Specialist will conduct a presentation to the rest of the team members validating the completion of each section of the form. 01/27/2026 Implemented
6400.217All consents had been signed by the individual 4's sibling although legal documentation was not provided. Additionally, the individual's admission packet that contained the consents did not have a signed copy for Medical/dental consent; however, a general consent for release of information for "medical care" and "no stop date" was dated 9/13/17 and signed by the individual's relative. Although, the individual, who is legally an adult, signed the Individual Rights form dated 9/11/25 where at section 32(b) the individual has civil and legal rights afforded by law, the relative continually signed the individual's documents.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. WHO: Administrative Staff WHAT: 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 WHEN and HOW · It was determined that the signatory on the individual's consent form was not the individual legal guardian. Therefore, the individual is not subject to guardianship and may consent independently. There is no other violation · Target dates:1/22/26 · Specific dates:3/31/26 A plan to prevent future occurrences · By ensuring that all required documents are signed by the individual and/or their legal guardian. 03/31/2026 Implemented
6400.24The Room and Board Residency Agreement (DP-1077) allows "[n]o more than 72 percent of the SSI maximum rate plus the Pennsylvania Supplement". Individual 4's room and board agreement dated 1-4-25 (signed by a relative and medical power of attorney on 3-24-25) charged $733.92, which appeared to exceed the maximum amount for 2025. Additionally, the room and board agreement dated 1-4-26 (which is only signed by the Agency's Program Specialist) charged $1243.93, which appeared to exceed the maximum amount for 2026.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.WHO: Administrative Staff b. WHAT: The home shall comply with applicable Federal and State statutes and regulations and local ordinances. c. WHEN and HOW · The Room and Board contract has been recalculated and signed by individuals and the right payee. In 2025, the individual was charged $753.92 but overpaid by $41.77 per month from January 2025 through March 2026. As a result, a total reimbursement of $626.55 will be issued to the individual. · Target dates:1/22/26 · Specific dates:/30/26 2. A plan to prevent future occurrences · Acute will calculate the room and board by using the lesser of the max benefit rate or the individual's SSI awarded + supplementary rate taken from the SSI federal payment amount website https://www.ssa.gov/oact/cola/SSI.html Example 1: Individual SSI awarded: $1000.00 Max Benefit: $994.00 Supplementary: $22.10 Room and Board calculation = 72% x (994.00 x 22.10) = 731.59 Example 2 Individual SSI awarded: $800.00 Max Benefit: $994.00 Supplementary: $22.10 Room and Board calculation = 72% x (800.00 x 22.10) = 591.91 03/30/2026 Implemented
6400.32(b)Individual 4's relative had signed as being informed of individual rights, but it was unclear whether legal paperwork existed to this effect. Additionally, the information sheet listed the mother as the primary point of contact.An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion.WHO: Program specialist WHAT: The dividual 4's relative had signed as being informed of individual rights, but it was unclear whether legal paperwork existed to this effect. Additionally, the information sheet listed the mother as the primary point of contact. WHEN and HOW · It was determined that the signatory on the individual's consent form was not the individual legal guardian. Therefore, the individual is not subject to guardianship and may consent independently. All forms requiring signature were resented to the individual and were resigned by the individual. There is no other violation · Target dates:1/22/26 · Specific dates:3/30/26 A plan to prevent future occurrences · Modify the intake process to require submission of documentation verifying legal guardianship by anyone claiming to be the individual's legal guardian. If no such documents in provided, the individual will assume his/her responsibility of signing all required documents. 03/30/2026 Implemented
6400.165(g)Individual 4 only had psychotropic medication reviews for March 4, 2025, and June 19, 2025, which the staff shared that the others had not occurred due to Crozer-Chester Hospital closure and the challenges of finding another provider. Currently, there is an appointment for February 26,2026.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.WHO: Program specialist WHAT: If medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. WHEN and HOW · All documents were retrieved from the licensed psychiatrist office reflecting the 3-month review period. There is no other violation · Target dates:1/22/26 · Specific dates:1/22/26 A plan to prevent future occurrences · Documentation will be promptly retrieved during each quarterly visit and stored according. 01/22/2026 Implemented
6400.166(a)(11)Individual 4's medication administration record (MAR) did not list the diagnosis or purpose for each medication, including pro re nata. Only two PRNs listed its purpose.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.a. WHO: Administrative staff /Program specialist b. WHAT: Diagnosis or purpose for the medication, including pro re nata c. WHEN and HOW · Diagnosis and purpose of medication have been added to MAR MARs for all individuals have been updated to include medical documentation, including diagnoses or the purpose for all medications · Target dates:1/26/26 · Specific dates:2/13/26 2. A plan to prevent future occurrences · By verifying that each individual record includes complete medical documentation, including diagnoses or the purpose for all medications 02/13/2026 Implemented
SIN-00221545 Renewal 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill was performed on 7/22/2022 and no other sleep drill was performed at the 6-month requirement.A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill was conduction on 3/27/23 to immediately fix the violation 03/27/2023 Implemented
6400.151(a)Most recent physical exam for staff #5 was completed on 3/15/21 and greater than two years have elapsed since this exam. 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. Staff #5 physical exam was retrieved from his PCP on 3/22/23 with a completion date of 3/6/23. 03/22/2023 Implemented
6400.46(b)Fire Safety Training for staff #5 was greater than 1 year apart. Dates are: 1/24/23 and 9/24/21 Fire Safety Training for staff #6 was greater than 1 year apart. Dates are: 2/24/23 and 9/24/21Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).A spreadsheet date chart was created to track each staff annual fire safety training, allowing administration to have an insight of soon to be overdue fire safety training. Because the last fire safety training for staff #5 was completed on 1/24/23, a new fire safety is not needed until 1/24/24. 04/24/2023 Implemented
SIN-00202664 Renewal 03/30/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Areas of disrepair: - There was no door frame inside of the bathroom doorway. - Baseboard heater in individuals' bedroom had unattached cover.Floors, walls, ceilings and other surfaces shall be in good repair. Importance of Regulation o Floors, walls, ceilings and other surfaces shall be in good repair to ensure that the home is presentable and safe for the individual Regulation Violated o There was no door frame inside of the bathroom doorway. o Baseboard heater in individuals' bedroom had unattached cover. Fixing Violation o Property management was contacted to finish the previously started construction and replace the door frame. The heater baseboard covers were also replaced and secured Prevent Future Violation o Establish space between the individual bed and the baseboard heater cover to prevent the bed from hitting the covers and causing any further damage. Also, encourage and establish a timeframe property management to complete renovations timely Responsible Person o Program Specialist, 04/15/2022 Implemented
SIN-00185602 Renewal 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)A written fire drill record was not kept of the date, time, the amount of time it took for evacuation, agency failed to provide October 2020 Fire 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. Regulation 6400.12C: Importance of Regulation o This regulation is critical for maintaining and ensuring the safety of the individual. Regulation Violated o A written fire drill record was not kept of the date, time, the amount of time it took for evacuation, agency failed to provide October 2020 Fire Drill. Fix of Violation. The October 2020 monthly fire drill was located in a different folder and immediately filed correctly. Responsible Person o Douglas Jones is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/15/21. o Violation was resolved on 3/29/21 o Based on analysis of other individuals, there are no similar violations. 03/29/2021 Implemented
6400.141(c)(6)The physical exam for Individual #1 indicated most recent TB Test dated was 6/24/15, TB test are to be completed every two years. No documentation of current TB test was provided at time of inspection.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. Regulation 6400. 141C.10 Importance of Regulation o This regulation is critical for maintaining good health of the individual. Regulation Violated o The physical exam for Individual #1 indicated most recent TB Test dated was 6/24/15, TB test are to be completed every two years. No documentation of current TB test was provided at time of inspection. The box on the individual¿s physical form which states `individual is free of all communicable diseases¿ was not checked by the physician. Fix of Violation o At individual's most recent PCP visit on 5/20/21, the PCP correctly filled the form out and indicated that the TB test had been completed. Responsible Person o Douglas Jones is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/15/21 o Violation was resolved on 5/25/21 o Based on analysis of other individuals, there are no similar violations 05/20/2021 Implemented
6400.165(f)Individual #1did not have a current Behavior Support Plan in the file at time of inspection, individual date of admission was 2/5/21.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Importance of Regulation o This regulation is critical for ensuring that staff persons supporting the individual are fully trained on the do¿s and don¿ts to adequately the individual. Regulation Violated o Individual #1did not have a current Behavior Support Plan in the file at time of inspection, individual date of admission was 2/5/21. Fix of Violation. o Acute Behavior Specialist worked closely with the County and other stake holder to draft a behavior plan. However, the individual did not return to Acute¿s program and the behavior plan was not finalized. Because the individual returned to the Selinsgrove center on 4/20/2021, directly from the hospital, the plan was not completed. Responsible Person o Victoria Tarpeh is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/15/21 o Violation was resolved on 4/15/21 o Based on analysis of other individuals, there are no similar violations 04/20/2021 Implemented
6400.213(1)(i)A dated Photograph for Individual #1 was not present in the individual records at time of inspection.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Regulation 6400. 213 Importance of Regulation o This regulation is critical for making sure the individual¿s records are up to date and to ensure all individual can be easily identified. Regulation Violated o A dated Photograph for Individual #1 was not present in the individual records at time of inspection. Fix of Violation. o The program specialist attempted to get a recent photo of the individual but was not accessible. The individual is no longer a part of Acute and decided she wanted to leave and return to Selinsgrove center. Responsible Person o Summer Kollie is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/20/21 o Violation was resolved on 4/20/21 o Based on analysis of other individuals, there are no similar violations 04/20/2021 Implemented
SIN-00157637 Renewal 06/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(d)There was no window covering in the bathroom window which was inside the shower.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. o Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger o There were no window covering in bathroom window which was inside the shower o It was noticed that an opposite window should be used to look directly in the bathroom window of the individuals were served o Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger o There were no window covering in bathroom window which was inside the shower o It was noticed that an opposite window should be used to look directly in the bathroom window of the individuals were served o Window privacy film was immediately installed to establish privacy o The window privacy film will be monitor by staff to ensure its existence and staff will report any damages to the window privacy film o Lead staff Anthony Kamara will be responsible to ensure there is no future violation by ensuring that the privacy film is in good condition o Acute anticipated the resolution of this violation by 6/27/19 o Violation was resolved on 6/27/19 o Based on analysis of other homes, there are no similar violations 06/27/2019 Implemented