Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258719 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)An application for a PA criminal history record check shall be submitted to the state police for prospective employees of the home within 5 working days of the person's hire date. Staff #2 date of hire was 3.4.24 and the criminal Check was not completed until 3.11.24. This exceeds the time frame.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Criminal background checks will now be completed on the date of hire, rather than the day the employee begins working directly with the individuals. 01/14/2025 Implemented
6400.81(k)(6)Individual bedrooms shall have a mirror. Individual #1 bedroom did not contain a mirror.In bedrooms, each individual shall have the following: A mirror. maintenance staff Installed a mirror on the back of individuals bedroom door 01/27/2025 Implemented
6400.106Furnace shall be inspected and cleaned annually. The documents provided for the furnace inspection and cleanings were dated for 12.6.23 and 1.10.25. This exceeds the annual time frame allotted by the regulation. The RCG reflects a 15 day grace period, however the cleanings have exceeded that time frame as well.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The residential manager will ensure the furnace is inspected and cleaned annually. 01/10/2024 Implemented
6400.110(a)A home shall have one operable smoke detector on each floor including the basement and attic. At the time of the inspection the basement smoke alarm was not activating when the main box was set off. The smoke alarms on the first and second floors were sounding. It was unclear as to why the basement alarm was not. The smoke detectors were on an interconnected system. The agency did purchase a battery-operated smoke detector for the basement and showed the licensing rep the correction the following day at another home inspection. However, at the time of the home inspection the basement smoke alarm was not operable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Installed a battery-operated smoke detector to the basement ceiling. 01/13/2025 Implemented
6400.141(c)(15)Individual #2 annual physical dated 6.24.24 states no diet restrictions or limitations, however individual #2 annual assessment dated 12.0.24 and ISP reflects he requires soft foods and small bites due to dysphagia (level 6). The physical did not properly reflect the diet.The physical examination shall include:Special instructions for the individual's diet. Staff that are taking the individual to the appointment will review the complete form and ensure all information is completed and accurate before leaving the office. 01/14/2025 Implemented
6400.181(e)(3)(iv)The annual assessment must include the individual's progress and growth over the last 365 days in personal adjustment. Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. The program specialist will update the current assessment to include the progress and growth over the last 365 days in personal adjustment and assistance required with personal needs. 01/28/2025 Implemented
6400.181(e)(13)(ii)The annual assessment must include the individual's progress and growth over the last 365 days in motor and communication skills. Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The program specialist will update the current assessment to include the progress and growth over the last 365 days in motor and communication 01/28/2025 Implemented
6400.181(e)(13)(iv)The annual assessment must include the individual's progress and growth over the last 365 days in personal adjustment. Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The program specialist will update the current assessment to include the progress and growth over the last 365 days in personal adjustment 01/28/2025 Implemented
6400.181(e)(13)(v)The annual assessment must include the individual's progress and growth over the last 365 days in socialization Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The program specialist will update the current assessment to include the progress and growth over the last 365 days in socialization. 01/28/2025 Implemented
6400.181(e)(13)(vii)The annual assessment must include the individual's progress and growth over the last 365 days in financial independence Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The program specialist will update the current assessment to include the progress and growth over the last 365 days in financial independence 01/28/2025 Implemented
6400.181(e)(13)(viii)The annual assessment must include the individual's progress and growth over the last 365 days in managing personal property. Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The program specialist will update the current assessment to include the progress and growth over the last 365 days in managing personal property 01/28/2025 Implemented
6400.181(e)(13)(ix)The annual assessment must include the individual's progress and growth over the last 365 days in community integration. Individual #2 annual assessment dated 12.10.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The program specialist will update the current assessment to include the progress and growth over the last 365 days in community integration. 01/28/2025 Implemented
6400.52(c)(1)Management, program, administrative staff shall have annual training in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. Staff #1 did not have documentation to reflect they received this training within the last training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Management staff/ trainer, will complete the training record to reflect their own training in application of person-centered practices, Community integration, individual choice and supporting individuals to develop and maintain relationships. 01/14/2025 Implemented
6400.52(c)(2)Management, program and administrative staff shall have annual training in the prevention, detection and reporting of abuse. Staff #1 did not have documentation to reflect they received this training within the last training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Management staff/ trainer, will complete the training record to reflect their own training in prevention, detecting and reporting abuse. 01/14/2025 Implemented
6400.52(c)(3)Management, program and administrative staff shall have annual training in individual rights. Staff #1 did not have documentation to reflect they received this training within the last training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Management staff/ trainer, will complete the training record to reflect their own training in individuals rights. 01/14/2025 Implemented
6400.52(c)(4)Management, program and administrative staff shall have annual training in recognizing and reporting incidents. Staff #1 did not have documentation to reflect they had this training within the last training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Management staff/ trainer, will complete the training record to reflect their own training in recognizing and reporting abuse 01/14/2025 Implemented
6400.165(g)If a medication is prescribed to treat symptoms of a psychiatric illness there shall be a review by a licensed physical every 3months that includes the documentation of the reason for prescribing the medication, then need to continue the med and the necessary dosage. The med reviews did not list the name of the medications and or their necessary doses or the reason to continue the meds. These reviews were completed on 4.30.24; 6.12.24 and 9.18.24. If a medication is prescribed to treat symptoms of a psychiatric illness there shall be a review by a licensed physical every 3months that includes the documentation of the reason for prescribing the medication, then need to continue the med and the necessary dosage. The med reviews did not list the medications and or their necessary doses on the medication reviews dated 10.24.24 or 7.25.24. (5.1.24 phone visit with Pa-Alexander Stine) ; (2.1.24 phone apt with Dr Berger, had medications)If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Staff that are taking the individual to the appointment will review the complete form and ensure all information is completed and accurate before leaving the office. 01/14/2025 Implemented
6400.213(1)(i)2131iv Individual record shall include their religious affiliation. This area of the individual record was left blank. *The actual citation number is 213 1i, which was not available in the drop-down menu.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The program specialist will ensure that no areas of the fact sheet are left blank, if information is not available or unknown than indicate that on the document. 01/14/2025 Implemented
SIN-00235596 Renewal 01/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The two most recent sleeping fire drills for this location were held on 04/26/2023 and 11/07/2023. The interim between these two sleeping fire drills exceeded the 6-month time frame requirement.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Manager will review the staffing schedule one week prior to due date of the drill and assign responsibility to the appropriate staff. Prior to assigning responsibility residential manager will review the previous fire drill records to ensure that drill is meets the regulatory requirements it is unannounced, on different days of the week, different time of the day (In this case sleeping hours) using different exits. The drill will be recorded and added to the fire drill records. 02/27/2024 Implemented
6400.141(c)(6)There was no record of Individual #1 receiving a Mantoux test within the individual record. The individual record contained two chest X-rays---dated 12/21/2021 and 04/27/2023---which the provider stated were performed on the individual in lieu of Mantoux skin testing. This individual does not have a record of a positive Mantoux skin test that would necessitate a chest x-ray; therefore, the individual must receive Mantoux skin testing once every two years, a requirement that was not met.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The individual is currently in a rehab facility so we will schedule an TB skin test with her physician if/when she comes home. 02/27/2024 Implemented
6400.213(1)(i)Individual #2's individual record does not contain information related to the presence or absence of identifying marks on the individual. An item on a client "Fact Sheet" found in the individual record reads "Identifying Marks:"; however, the area next to this item is blank. It is unclear whether the individual has no identifying marks or if this area was left blank unintentionally.Each individual's record must include the following information: (1) Personal information, including: (ii) The race, height, weight, color of hair, color of eyes and identifying marks.The intake staff will make sure that the Fact Sheet is completed completely leaving out no blanks including any identifying information such as identifying marks. 02/01/2024 Implemented
SIN-00216732 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The front porch and front door of the home was not lighted.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Will install a light next to the front door on the front porch of the home. 01/26/2023 Implemented
SIN-00197750 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling light in the upstairs bathroom was missing the glass globe/cover that covers the lightbulb. The entire surface of the heat register to the left of the toilet in the downstairs bathroom was covered in what appeared to be rust.Floors, walls, ceilings and other surfaces shall be in good repair. HHOS residential manager has hired a contractor to install a new radiator in the downstairs bathroom. He will also install a new light fixture with a covering in the bathroom upstairs. 02/28/2022 Implemented
6400.141(c)(3)Admission date for Individual #1 is documented as 10/15/21. The admitting physical for Individual #1 was completed on 10/1/21 and documented on Helping Hand Outreach Services Annual Physical Examination Form. The immunization section for Diphtheria and Tetanus of this form is marked as "unknown." Physical and items noted in the regulatory physical requirements are expected to be completed per regulation within 12 months prior to admission.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The staff will be retrained by the program director on proper documentation for all medical appointments. The training will include will emphasize that all areas of medical forms have explanations and completed thoroughly by the physicians and include any necessary explanation. 02/28/2022 Implemented
6400.32(v)The Individual Rights statement reviewed with and signed by the Individual (Individual #2) on 12/17/2021 did not include that an Individual's right may only be modified in accordance with 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. Individual rights for Individual #1 reviewed on 10/15/21 did not include a review that an individual's rights may only be modified in accordance with § 6500.155 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.The annual resident rights have been updated appropriately by the Director. All individuals have signed the revised Resident Rights relating to content of the individual plan to the extent necessary to mitigate a significant health and safety risk to the individual or others. 02/28/2022 Implemented
SIN-00182435 Renewal 02/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The stairs exiting the basement to the outside do not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. HHOS residential manager has hired a contractor to install a railing on the staircase existing the basement of the home. 04/12/2021 Implemented
6400.141(c)(3)The physical completed for Individual #2 on 9/17/2020 did not include the individual's immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The staff will be retrained by the program director on proper documentation for all medical appointments. The training will include will emphasize that all areas of medical forms are completed by the appropriate person. The staff will review each medical form to ensure it included immunization records and it has been completed thoroughly and there are no areas that are left blank or incomplete. 03/01/2021 Implemented
6400.141(c)(13)The physical completed for Individual #2 on 9/17/2020 did not include the Individual's allergies.The physical examination shall include: Allergies or contraindicated medications.The staff will be retrained by the program director on proper documentation for all medical appointments. The training will include will emphasize that all areas of medical forms are completed by the appropriate person. The staff will review each medical form to ensure it included allergies (even if there are none) and it has been completed thoroughly and there are no areas that are left blank or incomplete. 03/01/2021 Implemented
6400.142(a)Individual #2 has not seen a dentist since moving into the home on 7/1/09. While the individual refused in 2009, no visits or attempts have been made since then.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. As part of our existing desensitization plan the program specialist will report attempts to complete the necessary dental examinations annually unless otherwise stated in writing by the Dentist. The attempts will be documented on the dental exam form along with reports on the Desensitization plan directly. 04/07/2021 Implemented
6400.144Individual #2 does have a desensitization/refusal plan in her file, however there is no documentation that attempts were made to schedule dental or gynecologist appointments. There is also no documentation that the plan was utilized in educated the individual on the importance of attending above appointments.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. As part of our existing desensitization plan the program specialist will report attempts to complete the necessary gynecological examinations annually unless otherwise stated in writing by the Gynecologist. The attempts will be documented on the GYN exam form along with reports on the Desensitization plan directly. 04/07/2021 Implemented
6400.34(a)Individual # 1 and Individual # 2 signed their annual rights on 12-28-20 however, the individual rights have not been updated to reflect changes to the 6100 regulations.The home 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 home and annually thereafter.The annual resident rights have been updated appropriately by the Director. All individuals have signed the revised Resident Rights that reflect the 6100 regulations. The outdated Resident Rights has been removed from the file system. 02/15/2021 Implemented
6400.165(g)Individual #2 had documentation in her file with the "reason for visit" written as "psych med review" on the form on 7/6/2020, 9/17/2020, and 12/15/2020. There is no patient name written on the form for 9/17/2020 and no further verification that the appointment was for Individual #2. On 12/15/2020 the documentation provided is not for a psychotropic medication review, but for a follow up visit to treat the individual's asthma.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The staff will be retrained by the program director on proper documentation for all medical appointments. The staff will review each medical form to ensure it includes the intended purpose of the visit along with any other documentation and treatment provided by the physician or psychiatrist. 03/01/2021 Implemented
6400.166(a)(11)There is no diagnosis listed for medications on the MARS for Individual #1 or Individual #2.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 Medication logs have been updated by the Medication Trainer to include the medical diagnosis related to each medication. The staff will be retrained by the medication trainers to include the diagnosis on each MAR they are completing. 03/01/2021 Implemented
6400.181(f)Individual #1's assessment was completed on 10/4/20, his ARU date is 1/15/21, no documentation was provided that the assessment was sent to his team prior to his annual ISP meeting. Individual #2's assessment was completed on 8/1/20, her ARU is 11/1/20, no documentation was provided that the assessment was sent to her team prior to her annual ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.As part of the ISP implementation processes the program specialist will save a copy of the emailed invitation to the ISP team members including attached Assessment 30 days prior to the ISP meeting. The saved email receipt will be kept in the individual¿s file. 03/01/2021 Implemented
SIN-00147179 Renewal 12/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The ISP review covering July 2018 through September 2018 for Individual #1 was not signed and dated by the Program Specialist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The quarterly has been signed and reviewed by both the program specialist and the individual on 12/10/2018. Also on 12/10/2018 the program specialist reviewed all the quarterlies from the other individuals in the home and they were all signed and dated appropriately. One the 2nd Monday of every month the Residential Manager will review each individual¿s quarterly reports to ensure they are completed accurately and all information required is included in the report. The residential managers will then sign and date the report along with the Program Specialist and the individual. 12/10/2018 Implemented
SIN-00124156 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The section on Individual #1's physical form pertaining to the assessment of health maintenance needs was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Staff will be retrained on proper documentation for medical appointments. Training will include emphasis that all areas of the medical forms and documentation are completed. Staff will complete the sections of the medical forms that are necessary for the doctor to review prior to the appointments and make sure that the doctors have completed the sections they are responsible for. ((The physical forms have been faxed to the physician with a request to complete the missing information on 2/1/2018 -CH 2/6/2018)) 01/25/2018 Implemented
6400.141(c)(14)The section regarding information pertinent to diagnosis and treatment in case of an emergency was left blank on Individual #1's physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Staff will be retrained on proper documentation for medical appointments. Training will include emphasis that all areas of the medical forms and documentation are completed. Staff will complete the sections of the medical forms that are necessary for the doctor to review prior to the appointments and make sure that the doctors have completed the sections they are responsible for. ((The physical forms have been faxed to the physician with a request to complete the missing information on 2/1/2018 -CH 2/6/2018)) 01/25/2018 Implemented
6400.181(f)There was no documentation in either Individual #1's or Individual #2's file that showed the assessment was sent to the SC and team members at least 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Program specialist will include and attach the annual assessment to the invitations to the plan meetings within 30 days. to all team members. 01/22/2018 Implemented
SIN-00108685 Renewal 01/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)On staff #1's physical exam dated 5/27/2015, it does not state that she is free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The Staff individual will repeat the entire physical on HHOS employee physical form that includes a free from communicable disease statement requesting a physician signature. In the future when an applicant comes with a physical completed on another agency form the HHOS residential manager will review it to ensure it incudes a statement that the applicant is free from communicable disease. 03/08/2017 Implemented
6400.186(b)There are no signatures on the ISP review that was completed between 4/13-10/7/2016.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The Quarterly Review has been signed by both the individuals and the Program Specialist. In the future all quarterly ISP reviews will not be printed until they can be reviewed and signed by both the PS and the individuals . 03/01/2017 Implemented
SIN-00165217 Renewal 10/28/2019 Compliant - Finalized
SIN-00085893 Renewal 01/08/2016 Compliant - Finalized
SIN-00065994 Renewal 10/29/2014 Compliant - Finalized
SIN-00052259 Renewal 08/27/2013 Compliant - Finalized