Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00277462 Renewal 09/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The screen for the first-floor bathroom window had a hole in it.Windows, including windows in doors, shall be securely screened when windows or doors are open. Root Cause: The screen became damaged over time, likely from normal wear and tear or accidental pressure against the mesh. Staff did not notice the hole during routine cleaning and inspections. Immediate Corrective Action Taken: The damaged screen was removed and replaced with a new, fully intact screen. 10/30/2025 Implemented
6400.104-The letter to the Fire Dep't for 154 Taylor Ave Woodlyn PA 19094 indicates an address of 151 Taylor Ave.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Root Cause: The incorrect address was the result of a clerical error when preparing the fire department notification letter. The street name was inadvertently omitted, and only the town name and zip code were listed. This was an oversight during document preparation and not reflective of the correct property information maintained by the agency. Immediate Corrective Action Taken: A corrected fire department notification letter with the full and accurate address---154 Taylor Ave, Woodland, PA 19094---was prepared and sent to the local fire department immediately. Confirmation of receipt from the fire department was obtained and filed in the home's fire safety binder. The outdated letter was removed and replaced with the current, corrected version. 09/09/2025 Implemented
6400.181(e)(2)The 60-Day Assessment does not include the dislikes of the IndividualThe assessment must include the following information: The likes, dislikes and interest of the individual. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(5)The 60-Day Assessment does not include the individual's ability to self-administer medications.The assessment must include the following information:  The individual's ability to self-administer medications.Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(8)The 60-Day Assessment does not include the individual's ability to evacuate in a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(9)The 60-Day Assessment does not include documentation of the individual's disability including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(10)The 60-Day Assessment does not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(11)The 60-Day Assessment does not include psychological evaluations.The assessment must include the following information: Psychological evaluations, if applicable. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented
6400.181(e)(14)The 60-Day Assessment does not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Root Cause: This was a documentation oversight by the Program Specialist who completed the assessment. The required assessment elements were not omitted intentionally; however, the staff member failed to include all mandated sections when transitioning to a newly formatted 60-Day Assessment template. This resulted in several required areas being left incomplete. Immediate Corrective Action Taken: The 60-Day Assessment for the individual was immediately updated and corrected to include all required elements: Likes, dislikes, interests Ability to self-administer medications Fire evacuation ability and required support The individual progress Disability description with functional and medical limitations Water safety knowledge and swimming ability Lifetime medical history Psychological evaluations 10/15/2025 Implemented