Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265142 Renewal 04/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The annual onsite fire safety inspection by a fire safety expert was completed on 11/01/2023 and then again 11/07/2024. This exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.Serenitycare LLC. Ensure compliance with the requirement to have an annual onsite fire safety inspection conducted by a qualified fire safety expert. Documentation of the date, source, and results of each inspection will be maintained in accordance with regulatory standards. 05/02/2025 Implemented
2380.91(c)Fire safety training documentation does not include the content of training. The training form signed by Individual #1 on 3/18/2025 states this is the following information that was covered: "direct care worker: exit facility immediately, meet at front gate, and get out and stay out." Program Specialist/Director #1 stated they watch a video as well that discusses general fire safety. They also review evacuation procedures, responsibilities during fire drills, and the designated meeting place. It just is not documented. The document including Individual #3 fire safety training completed on 2/06/2025 did not include the entire content of the training. The training form signed by Individual #3 on 2/06/2025 states this is the following information that was covered: "direct care worker: exit facility immediately, meet at front gate, and get out and stay out." Program Specialist/Director stated they watch a video as well that discusses general fire safety. They also review evacuation procedures, responsibilities during fire drills, and the designated meeting place. It just is not documented. The document including Individual #4 fire safety training completed on 8/6/2024 did not include the entire content of the training. The training form signed by Individual #4 on 8/6/2024 states this is the following information that was covered: "direct care worker: exit facility immediately, meet at front gate, and get out and stay out." Program Specialist/Director stated they watch a video as well that discusses general fire safety. They also review evacuation procedures, responsibilities during fire drills, and the designated meeting place. It just is not documented.A written record of firesafety training, including the content of the training and individuals attending, shall be kept.Serenitycare LLC has compiled and organized all fire safety training documentation conducted within the past 12 months. The written records now include the following: a detailed outline and content of each fire safety training session; the names and signatures of all participants in each session; the date, time, and location where each training was held; and the name and qualifications of the individual(s) who conducted the training. These records are maintained in compliance with 55 PA Code Chapter 2380.84. 05/09/2025 Implemented
2380.181(e)(11)Individual #1 assessment completed on 3/31/2025 did not include a psychological evaluation. Individual #2 assessment completed on 6/14/2024 did not include a psychological evaluation. Individual #3 assessment completed on 2/11/2025 did not include a psychological evaluation. Individual #4 assessment completed on 7/11/2018 did not include a psychological evaluationThe assessment must include the following information: Psychological evaluations, if applicable.Serenitycare LLC will ensure that the annual assessment includes all required components, specifically psychological evaluations, as outlined in the regulation. The Program Director will be responsible for ensuring that appropriate efforts are made to obtain the required psychological evaluations. All attempts and correspondence to secure these evaluations will be thoroughly documented, and receipt of the evaluations will be maintained in the individual's record to ensure regulatory compliance. 05/09/2025 Implemented
SIN-00244590 Renewal 05/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(12)Individual #1's assessment, completed 4/2/24 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Serenity care will ensure thatb each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. 06/13/2024 Implemented
2380.21(u)Individual #1 was informed of their individual rights on 1/6/23 and then again on 2/3/24.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Program Specialist underwent retraining following 55 PA Code Chapter 2380.21(u). The facility shall inform an individual of rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter 06/13/2024 Implemented
2380.122(a)Direct Service Worker #2's Medication Administration Course Training was not completed when Hydroxyzine Pamoate 50 mg was administered to Individual #2 at 12:00PM on 5/6/24, 5/8/24, 5/9/24, and 5/10/24. Direct Service Worker #3's Medication Administration Course Training was not completed when Hydroxyzine Pamoate 50 mg was administered to Individual #2 at 12:00PM on 5/1/24, 5/3/24, and 5/7/24.A facility whose staff persons are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Medication administration for individuals will only be done by staff who has completed the required Department-approved medication administration course, including the course renewal requirements. 06/13/2024 Implemented
2380.126(a)(2)Individual #2's May 2024 daily Medication Administration Records did not include name of the prescriber for Hydroxyzine Pamoate 50 mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. The program specialist and or Medication designee will ensure that a medication record is kept, including the name of the prescriber for each individual 06/13/2024 Implemented
2380.126(a)(3)Individual #2's May 2024 daily Medication Administration Records did not include drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. The program specialist and or Medication designee will ensure that a medication record is kept, including the drug allergies for each individual 06/13/2024 Implemented
2380.126(a)(11)Individual #2's May 2024 daily Medication Administration Records did not include the diagnosis or purpose for Hydroxyzine Pamoate 50 mg.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 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. The program specialist and or Medication designee will ensure that a medication record shall be kept, including the Diagnosis or purpose for the medication, including pro re nata for each individual 06/13/2024 Implemented
2380.129(d)Direct Service Worker #1's Medication Administration Course Training did not include the date that the training was completed. Direct Service Worker #1 administered Individual #2's medication Hydroxyzine Pamoate 50 mg at 12:00PM on 5/2/24, 5/13/24, and 5/14/24.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Serenitycare training designee will ensure that a record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was completed 06/13/2024 Implemented
SIN-00208135 Renewal 07/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Individual #1's record did not include the individual's hair color and identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.POC - The Individual Personal Information Document was modified to include a red asterisk for all required fields. 07/18/2022 Implemented
2380.181(a)Individual #1 had an assessment completed 4/27/2021 and again on 5/25/2022. This exceeds the annual requirement.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.P0C - Program Specialist Task document has been modified to reflect the Annual Assessment due date be performed at least 30 days prior to the scheduled ISP meeting. 08/01/2022 Implemented
2380.38(b)(4)Direct Services Worker #1, date of hire 5/26/2022, did not complete the following training topic during orientation: Recognizing and Reporting Incidents. Direct Services Worker #2, date of hire 5/23/2022, did not complete the following training topic during orientation: Recognizing and Reporting Incidents.The orientation must encompass the following areas: Recognizing and reporting incident.POC: The New Hire training syllabus has been modified to include the Recognizing and Reporting of Incidents within the 1st 30 days of hire. 08/01/2022 Implemented
2380.181(f)Individual #1's assessment was provided to the individual plan team members on 6/9/2022 and the plan meeting was held on 6/1/2022. The assessment was not provided at least 30 calendar days prior to the individual plan meeting. Individual #2's assessment was sent to the plan team 5/9/2022. The plan meeting was held on 5/9/2022. The assessment was not provided at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.P0C - Program Specialist Task document has been modified to reflect the Annual Assessment due date be performed and mailed to client team at least 30 days prior to the scheduled ISP meeting. 08/01/2022 Implemented
SIN-00226058 Renewal 06/13/2023 Compliant - Finalized
SIN-00193919 Renewal 08/12/2021 Compliant - Finalized
SIN-00174359 Initial review 09/11/2020 Compliant - Finalized