Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00277600 Renewal 11/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 11/5/25 at 11:50am a 32 oz bottle of Scrubbing Bubbles disinfectant was found under the bathroom sink.Poisonous materials shall be kept locked or made inaccessible to individuals. In accordance with PA Code Chapter 6400.62(a) poisonous materials shall be kept locked or inaccessible to individuals. 12/29/2025 Implemented
6400.151(a)Direct Service Worker #1, date of hire 10/10/23, had a physical examination dated 9/8/23. This exceeds the every 2-year requirement. 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. In accordance with 55 PA Code 6400.151 (a) 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. 12/18/2025 Implemented
6400.181(e)(4)Individual # 1's assessment, dated 5/9/25 indicated the individual needed close supervision in the community, but did not address the individual's supervision needs in the home. The assessment must include the following information: The individual's need for supervision. In accordance with 55 PA Code 181 (e) (4) the assessment must also address the individual's need for supervision in the home. 12/29/2025 Implemented
6400.181(e)(9)Individual # 1's assessment, dated 5/9/25 had no documentation of the individual's disability.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. In accordance with 55 PA Code 6400 (e) (9) the assessment must include documentation of the individual's disability, including functional and medical limitations. 12/29/2025 Implemented
6400.181(e)(10)Individual # 1's assessment, dated 5/9/25 did not contain the individuals lifetime medical history.The assessment must include the following information: A lifetime medical history. In accordance with 55 PA Code 181 (e) (10) the assessment must contain the individual's lifetime medical history. 12/29/2025 Implemented
6400.181(e)(12)Individual # 1's assessment, dated 5/9/25 had no recommendation for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. In accordance with 55 PA Code 6400 (e) (12) the assessment must include recommendations for specific areas of training, programming and services. 12/29/2025 Implemented
6400.18(i)Enterprise Incident Management incident #9647868 had a due date for the incident final section of 7/20/25. The incident final section was submitted by the agency on 8/13/25. No extension was filed for this incident.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.In accordance with 55 PA Code 6400 (18) (i) the provider shall finalize any incident report through the Department's information management system within 30 days of discovery of the incident by a staff person unless the provider notifies the Department in writing that an extension is necessary and the reason for the extension. 01/16/2026 Implemented
6400.166(a)(13)Direct Service Worker #1 administered Melatonin 10 mg to Individual #1 on 11/3/25 at 8:00pm. Direct Service Worker #1 initialed the Medication Administration Record, (MAR) on 11/3/25 at 8:00 pm as administering the medication; however, DSW #1 did not sign and initial the Master Legend of staff administering medications on 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.In accordance with 55 PA Code 6400. 166 (a) (13) 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-00258115 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-00181825 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 January28, 2021, (Program Specialist) complete the self assessment. 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, without a completion date, was provided to the Department. (AES,HSLS on 2/23/21)] 02/01/2021 Implemented
6400.110(c)The only smoke detector in the home is in the bedroom of the home.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. On January 29, 2021, Joanne Walker (Program Specialist) purchased a placed smoke detector outside of bedroom within 15 feet of the bedroom. The Program specialist will immediately audit all homes quarterly for 1 year for smoke detectors location to ensure compliance is being met. Within 30 days of receipt of plan of correction, all staff will be trained by program specialist on regulation 6400.110. The CEO will audit all location quarterly for 1 year to ensure the violation do not reoccur in the future. Documentation will be kept. [At least monthly, all smoke detectors will be checked to ensure operability, as required, and documentation of the checks will be kept. Audit documentation for monthly and quarterly audits of smoke detectors signed by CEO on 1/30/21 was provided to the Department on 2/22/21. (AES,HSLS on 2/23/21)] 01/29/2021 Implemented
SIN-00215238 Renewal 11/22/2022 Compliant - Finalized