Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259099 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The community bathroom in Forrest Hall-Hall C has faucets producing waters opposite of their labels.Floors, walls, ceilings and other surfaces shall be in good repair. The faucet in the community bathroom in Hallway C has been fixed, attachment. 02/19/2025 Implemented
6400.77(b)The First Aid Kit did not contain scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The scissors were replaced in the kit. 01/16/2025 Implemented
6400.144For Ind. #10: There was no prostate exam in the records at the time of the review. The individuals AIC check in 3/26/24 and a follow-up check was due by October 9, 2024. There was no indication in the record at the time of the record that a AIC test was completed by the due date. For Ind. #9: The annual physical dated 2/16/2024 for the individual noted that there was a prostate exam completed on 2/7/22. The attending physician wrote that the exam was negative, however there was no prostate exam completed for 2023 and 2024. Also, there were no labs indicating the results of the 2/7/22 prostate test results in the record at the time of the review. The individual was born in 1973 and is over the age of 40, therefore a prostate exam should be completed yearly according to the regulations. For Ind. #8: The individual records indicated that a follow neurological exam was to be completed by August 2024, however there was no appointment noted in the record at the time of the review. Medication review for Ind. #7: The Genteal tear sol mod pf (PRN) was not in the nurses' office. It was reported that it was ordered a few days ago. Medication review for Ind. #6: The Genteal tear sol mod pf (PRN) was not in the nurses' office. It was reported that it was ordered a few days ago.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. Individual #10 had bloodwork drawn on 10/7/24. The test was not performed as specimen was received clotted. Individual #9 has his annual physical exam scheduled for 2/19/25. Individual #8 had a neurological follow-up appointment completed on 8/27/24. The pharmacy was called, by the nurse charge and the medication was prioritized for same day delivery. 02/12/2025 Implemented
6400.163(a)For Ind. #7: The PRN ChapStick, and the PRN fleet enema, did not have script labels on the packaging.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Labels were created and signed by the prescriber and placed on the ChapStick, and fleet enema. 01/16/2025 Implemented
6400.167(a)(1)It cannot be determined that Individual #5 has received all dosages of Docusate 250mg between the dates of 1/1/25 and 1/14/25. The blister pack for this medication had 11 pills removed at time of review, though the order for the medication indicates two of these pills should be taken at each administration. 8 pills should be left based on the blister pack per medication's order. The medication's administration is also tracked inconsistently on their MAR as dates in which it was reported that the Individual was with family, there are signatures present indicating that the medication was given by Staff (1/12/25).Medication errors include the following: Failure to administer a medication.A MAR audit was completed to verify if all dates between 1/1/25-1/14/25 were initialed by staff indicating that the medication was given. It is noted that client was with family on 1/12/25. 01/15/2025 Implemented
SIN-00238503 Renewal 01/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The Hot water temperature registered at 132.8 degrees at time of inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temp was reset by maintenance and tested, attachment. 01/24/2024 Implemented
6400.76(c)C Hall- the bathroom between rooms 5 & 6, the toilet paper holder was missing.Furniture shall be comfortable and home-like. Toilet paper holder was replaced by maintenance, attachment. 01/30/2024 Implemented
6400.112(i)On 3/12/23 the drill does not indicate, method of notification/alerting Technique. Emergency Equipment System/equipment check is (blank) Suppression equipment and Fire extinguishers was (blank) A fire alarm or smoke detector shall be set off during each fire drill.On 3/12/23 drill, the method of notification/alerting techniques as well as emergency system/equipment¿s¿ check were indicated by being underlined and bolded, attachment. 01/24/2024 Implemented
6400.141(c)(9)There was no documentation of a completed prostate exam for Individual #7.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #7 had a physical examination and was noted to not have an enlarged prostate, attachment. 02/14/2024 Implemented
6400.144Individual #5 -- Med Fluocin Acet Sol 0.01%, 8pm on order. Medication ran out the previous night. No verification was provided as to when the medication was delivered or when delivered,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. Medication delivered by pharmacy 01/23/2024 Implemented
6400.144December physical comments that Individual #5 glasses broke "a few months ago." There was no documentation indicating that these had been repaired or replaced.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. Mark had two pairs of glasses ordered on 2/1/24. Delivered to mark on 2/14/24, attachment. 02/14/2024 Implemented
6400.183(c)The ISP meeting sign-in sheet was not found in the record of Ind. #5.The list of persons who participated in the individual plan meeting shall be kept.A 1st warning was issued to the Records department staff on 4/12/2024 who failed to upload the signature page of the ISP to the individual's electronic health record (EHR), attachment. 04/12/2024 Implemented
SIN-00218724 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Bleach was found not in its original labeled container, under the kitchen sink.Poisonous materials shall be stored in their original, labeled containers. Supervisors will complete daily rounds in respective homes to ensure chemicals are properly secured with proper labeling. 03/16/2023 Implemented
6400.64(a)The bathroom light connected to room 18, was full of debris or dust.Clean and sanitary conditions shall be maintained in the home. A housekeeping checklist was developed that managers will ensure is used by all housekeeping staff; Implementation of this checklist will be checked minimally, once/month. 04/30/2023 Implemented
6400.141(c)(9)There is no current Prostate Exam on file for individual 2.The physical examination shall include: A prostate examination for men 40 years of age or older. Program Quality & Utilization Review Specialist directed all Medical Assistants to ensure prostate examination for all men over 40 years of age completed at time of Annual Physical Examination. This was completed on 3/7/2023. 03/07/2023 Implemented
6400.163(h)The medication storage location had an Expired Epi-Pen (November 2022) for individual 1. There was an additional pen located in the medication box that was that was not expired that was available for the individual.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.As part of the 2021 POC, an assigned MTS will perform medication cart checks on a weekly basis to ensure any expired or discontinued meds are appropriately removed from the cart. This plan reduced the number of medication storage citations by 75%. Nursing staff will continue to complete weekly med cart checks. 03/31/2023 Implemented
6400.165(b)Individual 1's prescription Pseudoephedr Tab 120 had inconsistent labels. Current active order states 1 tablet every 72 hours as needed for Headache/ Congestion, however there was a box that said 1 tablet once a day as neededA prescription order shall be kept current.Nursing staff will continue to complete weekly cart check and document and remove any discontinued, expired medications. Nursing staff will also check and ensure that when medication orders are changed prescription label matches the order and PCP will relabel as needed. Nurse manager will review cart checks monthly. 03/31/2023 Implemented
6400.166(b)On 1/3/23 all 8pm medications were not initialed as having been administered for individual 1. Those medications are as follows: Banophen 50 MG 2 Capsules by mouth at bedtime, Desmopressin Tab 0.2MG, Two Tablets by mouth every evening at 8pm for Enuresis, Diazepam Tab 5MG, 1 Tablet my mouth at bedtime for Insomnia, Trazadone 150MG ½ tablet by mouth at bedtime, Oyster Shell Tab 500MG 1 Tablet by mouth at bedtime, and Advair Diskus, 1 Puff my mouth Twice a day Medication prescribed to individual 2, Alendronate Tab 70mg -- One tablet by mouth once a week on Monday was not initialed as administered on 1/9/23.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Nursing staff will continue to check MARs for missing initials weekly. Nurse Manager will review MARs for missed initials monthly. 03/31/2023 Implemented
6400.181(f)The annual assessment for individual 2 was sent to the team on 8/12/22 and the ISP meeting was held on 9/7/22 which is fewer than 30 days.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Assessment timelines, expectations and the importance of meeting regulatory requirements will be reviewed with the Case Manager by the Assistant Director of Case Management. 03/17/2023 Implemented
SIN-00199975 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen contained cleanliness issues. There were Cheetos and pretzels in the cabinet and splatters on the wall across from the refrigerators.Clean and sanitary conditions shall be maintained in the home. Cleaned on 2/2/2022. On 3/2/22, Residential Manager, completed a walk through of Forrest hall and all cabinets are clean and organized. 03/31/2022 Implemented
6400.67(a)Room 32 had missing knobs on the dresser which rendered one drawer without any knobs and so it was difficult to open. ** Email received showing that this was fixed.**Floors, walls, ceilings and other surfaces shall be in good repair. Replaced on 2/2/2022. On 3/2/22, Residential Manager, completed a walk through of Forrest hall and all dresser knobs are present. 03/31/2022 Implemented
6400.72(b)There was missing window glass in the room of Individual #1. This was reported to have been removed in order to put in a window unit but it was not replaced. Screens, windows and doors shall be in good repair. Maintenance request submitted. NOTE: the window is a special order and Woods is waiting for the product to be in stock. On 3/2/22, Residential Manager, completed a walkthrough of Forrest hall and all other windows are in good repair. 03/31/2022 Implemented
6400.81(k)(6)There was no mirror in room 32 ** Email received on 2/3 showing this was installed**In bedrooms, each individual shall have the following: A mirror. On 2/11/2022, it was confirmed via email, by Care Coordinator for individual in this room, that the individual residing in bedroom 32 has has/had a mirror that is located on the back of his bedroom door. As of 3/1/22, the Director of Care Coordination confirmed that all other remaining residents are in compliance. 03/01/2022 Implemented
SIN-00183417 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual#1was seen for Annual Dental Exams on 08/07/2019 and 02/03/2021. The period between these two exams exceeds 1 year and is therefore outside of regulatory compliance.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The Dental clinic was closed for the Months of April, May and June of 2020 due to restrictions set by the Centers for Disease Control and the Pennsylvania Dental Association to postpone annual checkups, elective procedures and non-urgent dental visits during the height of the COVID-19 pandemic. 03/23/2021 Implemented
6400.181(a)Per Individual#2's Individual Record, the two most recent Annual Assessments were compiled on 12/19/2019 and 01/29/2021. The Assessment was not updated on an annual basis as required. 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. There is an error in this citation. A Resident Assessment was completed for Charles on 7/2/2019 then a Revised Resident Assessment was completed on 12/20/2019 then his annual Resident Assessment was completed on 7/2/2020 then another Revised Resident Assessment was completed on 1/29/2021. Attachments # 1. 03/23/2021 Implemented
6400.181(f)There is no evidence within the Individual Record to indicate that individual#1s Annual Assessment (dated 10/09/2020) was sent to the members of the Individual Support Plan (ISP) Team at least 30 days prior to his ISP Annual Review Meeting, which occurred on 11/19/2020.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 detailed email was sent to the Care Coordinators on 3/22/2021 stating the enforcement of Resident Assessment completion expectations moving forward. Attachment #2 03/23/2021 Implemented
SIN-00156310 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Two bottles of poisons were not stored in their original containers and were re-labeled air freshener and carpet cleaner.Poisonous materials shall be stored in their original, labeled containers. The chemicals were put in the correct container with ODP inspection during the walk through.  Program supervisor completed immediately.  Since it is unknown who placed the chemicals in the incorrect container, housekeeping staff were issued a memo to address the concern. (attachment 5) 07/01/2019 Implemented
6400.67(a)Bathroom number 19 had a rusted toilet support rail. The top dresser nob handle for individual #22's dresser was missing.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submited to replace the rusted toilet support rail. A new rail was installed on 05/17/2019. A monthly enviromental inspection will be completed by the Residential Supevisor. Any issues will be addresed and forwarded to the Residenital Director. (attachment 4) 05/17/2019 Implemented
6400.67(b)Individual #24's bed rails were not working properly and were hazardous. Floors, walls, ceilings and other surfaces shall be free of hazards.The bed was removed from the bedroom on 05/10/2019 by the Residenital Manager. A new bed not requiring bed rails (Prime Care P301) along with a impact reduction mat (Prime Mat 2.0) was ordered by the Residential Director on 05/02/2019. The bed was delivered and placed in the resident's bedroom on 05/10/2019. A monthly environmental inspection will be completed by the Residential Supervisor. Any issues will be addressed and forwarded to the Residential Director. 05/10/2019 Implemented
6400.141(c)(4)Individual #23's annual physical exam dated 11/17/18 did not indicate a current hearing test. The last hearing test in the medical file was dated 2/27/18.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individuals referred by physician and/or family and individuals who have a known audiological issue will be scheduled to have a hearing screening. The request will be processed via a physician recommendation. There is no physician recommendation for this resident. 07/08/2019 Implemented
6400.141(c)(13)Individusal #23's annual physical exam dated 11/17/18 did not indicate allergies.The physical examination shall include: Allergies or contraindicated medications.Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include allergies/adverse reactions after the Problems section. Primary Care Physician is now able to review this information. (attachment 2) 07/08/2019 Implemented
6400.141(c)(14)Individual #22's physical exam dated 2/25/19 did not include information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Eileen Fox, Systems Analyst, updated the Annual Physical Exam report to include medical information pertinent to diagnosis and treatment in case of emergency under the PE 2 section. Primary Care Physician is now able to indicate this information was reviewed as indicated. (attachment 2) 07/08/2019 Implemented
6400.241(b)The kitchen freezer that stored food measured 20 degrees FahrenheitFood shall be kept at the proper temperature. Cold food shall be kept at OR below 45°F. Hot food shall be kept at OR above 140°F. Frozen food shall be kept at OR below 0°F. A work order was submited to assess and make repairs to the freezer. The system was checked and the units were cleaned 05/08/2019. Monthly refrigerator and freezer temperatures are taking by a member of the panty staff. Any issues will be reported to the maintenance department. Temperature forms will be submitted to the Compliance and Licensing department on a monthly basis for review and filing. (attachment 1) 05/08/2019 Implemented
SIN-00133738 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Individual #1 and #2's photographs on record were taken on 2/25/13.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Picture was updated on 3/1/18 (attached pictures). Going forward to stay compliant pictures will be taken every four years. Records Services will make sure this gets accomplished. 03/01/2018 Implemented
SIN-00108181 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The ventilation in the bathrooms between bedrooms was inoperable.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Ventilation was repaired by Woods maintenance department on 3/21/17. (see attachment) Residential Manager will complete monthly environmental inspections to ensure no areas of noncompliance. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. Any area of non-compliance will be forwarded to Residential Director. 02/15/2017 Implemented
6400.162(a)Individual #1's prescription ONFI Suspension the label did not include the frequency that the medication is to be administered. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Individual #1's prescription label for ONFI Suspension was corrected to include the frequency that the medication is to be administered. Going forward, the nurse or medication trained staff will complete daily checks of the medication cart to ensure all medications are labeled accordingly. If any need to be corrected, the medication trained staff or nurse will have it completed immediately and/or address the concern with nursing management who will ensure completion. (see attachments) 04/03/2017 Implemented
SIN-00063870 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(d)(1)Individual #2's previous ISP start date was 10/10/12-10/9/13. The current ISP start date is 11/9/13-11/10/14 exceeding the annual due date. The plan lead shall develop, update and revise the ISP according to the following: The ISP shall be initially developed, updated annually and revised based upon the individual's current assessment as required under § § 2380.181, 2390.151, 6400.181 and 6500.151 (relating to assessment). This issued occurred while Mollie Woods Program Specialists were still becoming familiar with the differences in the ISP meeting date vs. the effective date. Since September 2013, Mollie Woods Program Specialists began making the ISP effective date 30 days following the ISP meeting date and the ISP will remain effective for the next 12 months unless a critical revision is required. This change was linked to changes made in the ISP 3 month review form. (See attachments G&H) [The ISP meeting will be completed on a date that allows for the ISP to be finalized and implemented within one year of the previous ISP effective date. LAC 1/26/15] 08/01/2014 Implemented
6400.186(a)Individual #1's previous ISP review was dated 1/3/13. The next ISP review was completed on 6/13/13, and then on 10/13/13, exceeding every three months. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The issue of reviewing and signing the ISP's within 2 weeks of the end of the review period was discussed with the Program Specialist,and by Director of Program Coordination on October 15, 2014. (See attachment A) For individual #1, ISP 3 month reviews were completed as follows: Review#1 March 2013, signed 4/10/13; Review #2 June 2013, signed 6/3/13; Review #3 covered 6/3/13-9/2/13, signed 10/13/13(late); Review #4 covered 9/3/13-12/2/13, signed 1/13/14 (late) (See attachments B) ISP 3 month reviews will occur no more than every 90 days. Effective, April 1, 2014, changes in ISP meeting dates and effective dates will be accounted for and adjustments will be made to ensure that ISP 3 Month reviews do not exceed 90 days. This will be monitored by the Program Specialist, Program Planning Coordinator and/or Director, Program Coordination on a monthly basis. Program Specialists were informed of the new procedure for submitting the ISP 3 Month Reviews in a detailed Memo issued 2/14/14 (See attachment C) and at length during monthly meetings on 2/18/14 and 3/18/14. (See attachments D&E) A reminder email was sent to Program Specialists on 10/7/14. (See attachment F) 10/15/2014 Implemented
SIN-00091277 Renewal 10/26/2015 Compliant - Finalized