Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285385 Unannounced Monitoring 03/20/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)Individual #1 was given their dose of Metformin 500 mg on 3/20/2026 as prescribed for 9am but staff failed to initial the medication as administered on the MAR. The dose was missing from the blister pack.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.The staff member responsible completed full retraining by 03/26/2026, including medication administration procedures, documentation requirements, and identification and prevention of medication and documentation errors. The retraining reinforced the requirement to initial the MAR immediately after administering any medication, in accordance with 55 PA Code 6400.166(a)(1--3) Effective immediately, the Program Specialist will conduct weekly MAR reviews for the next 60 days to ensure all medication administrations are documented accurately . Any discrepancies identified during these reviews will be addressed the same day with corrective coaching and, if necessary, additional retraining 03/26/2026 Implemented
SIN-00190578 Renewal 07/20/2021 Compliant - Finalized