Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259839 Renewal 02/05/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The four corners of the walls in the basement and several spots in the center of the wall to the right when walking down the steps have what appears to be black mold. It is unclear if it is black mold or areas of dirt. This covers a significant portion of each corner from ceiling to the middle of the walls with the corner closet to the washer and dryer being the worst.Clean and sanitary conditions shall be maintained in the home. ServPro came to inspect Beach Lake basement on 2/10/25. Samples were taken and analysis completed. It was determined to be mildew. The report will be kept on file and a copy provided if necessary The basement will be treated to remove mildew and treated with DryLock. 04/15/2025 Implemented
6400.72(b)The small horizontal window in the basement on the wall to the right of the stairs when walking down the stairs is broken. Screens, windows and doors shall be in good repair. New window has been ordered and will be installed when received. 04/15/2025 Implemented
SIN-00238359 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency telephone numbers were not posted on or near the telephone located in Individual #1's bedroom.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. All required emergency telephone numbers were posted on the wall next to Individual #1¿s telephone immediately following the inspector leaving the home. 03/12/2024 Implemented
SIN-00217280 Renewal 02/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)Individual records are not locked when unattended. There were five boxes located in the basement of the home that were identified as individual records. These boxes were not locked and were easily accessible upon entering the basement. An individual's records shall be kept locked when unattended. The boxes of individual records located in the basement will be relocated to the Main Office and placed in locked storage area. (The records contained in the boxes are for individuals that have passed away.) 03/08/2023 Implemented
6400.31(a)Individual #1, Individual #2 and Individual #3 were deprived of their rights. Individual #1, Individual #2 and Individual 3 are deprived of their ability to shower independently and for the length of time which the Individuals choose due to access of running water in the shower. Individual #1, Individual #2 and Individual #3 do not have access to running water in the shower without asking staff to turn the timer on the water on. The water is timed and turns off after 15 or 30 minutes. The timer is located behind the basement door that is locked and inaccessible to all Individuals in the home.An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.).The valve for shower water in basement was turned at time of inspection to bypass the timer, thereby allowing access to running water in the shower at all times. 02/23/2023 Implemented
6400.165(c)Medications are not being administered as prescribed. Individual #1 is prescribed Ciprodex Otic Susp, place 4 drops in the right ear 3 times daily for two weeks. The date on the prescription label was June 8, 2022. The Medication Administration Label states: Ciprodex Otic Susp, place 4 drops in right ear once a day. The medication was documented as administered until August 11, 2022, at which time it was placed on hold by Individual #1's Ear, Nose and Throat specialist. The medication was to be administered for two weeks beginning in June. There were no additional orders indicating a change to the dosage and administration of the medication. It is unknown if the medication was administered following the two-week time that it was ordered for or what the correct orders for the medication were.A prescription medication shall be administered as prescribed.Agency located written documentation from the physician placing the medication on hold. If the physician requests the medication to be restarted in the future, a new order will be obtained with the correct time frame of administration. 03/06/2023 Implemented
SIN-00200565 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)The fire drill record conducted on 4/25/21 did not include the designated meeting area on the fire drill as this area was left blank on the form. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Meeting place/fire safe area will be prepopulated on all fire drill forms 03/31/2022 Implemented
6400.165(g)Individual #1 had a 3-month psychiatric medication review completed on 11/8/21 review which did not include documentation of the reason for prescribing the medication, and the need to continue the medication.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.Program Specialist will make sure all medication review forms are completed entirely to include documentation of the reason and need to continue the medication. Individual resident "Face Sheets" which provide a current list of medications and reason prescribed, will be attached to each medication review form. 03/31/2022 Implemented
SIN-00178832 Renewal 10/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The main bathroom of the home did not have paper towels or cloth towel to dry their hands. (*this was corrected at the time of the inspection)Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.   11/24/2020 Implemented
SIN-00158480 Renewal 07/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this chapter expired on 7/1/2019. A Self-Assessment wasn't completed until 7/19/2019.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. 55 PA Code Chapter 6400.15(a) - Program Specialist will complete a self-assessment of each home during the month of October, January and April. All self-assessment will be dated to ensure compliance 07/30/2019 Implemented
6400.110(f)Individual #2 requires a bedshaker at this residence. At the time of this inspection, his bedshaker was not working when the smoke detectors were tested. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. 55 PA Code Chapter 6400.110(f) - Bedshaker compatible with fire alarm system has been ordered and is scheduled to be installed by alarm company on 8/22/19 08/22/2019 Implemented
6400.112(d)Individual #1 refused to evacuate for fire drills conducted on 12/20/2018, 2/22/2019, and 3/20/2019 while he resided at this residence. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 55 PA Code Chapter 6400.112(d) - Refusal policy has been initiated as follows - If individual refuses to evacuate during fire drill the drill will be repeated the following day/time. If individual refuses to evacuate the second time the drill is initiated staff are to contact Residential Director for instruction. Staff persons are always present at the home while individual is at the home to provide assistance. 07/31/2019 Implemented
SIN-00134447 Renewal 06/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)While the home has an extended evac time of 3.5 minutes, the 02-23-18 drill lasted 5 minutes and 2 seconds and one of the individuals never got out. His training is documented and ongoing. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 55 Pa Code Chapter 6400.112(d) - All individuals will evacuate the home within the evacuation time required to the fire safe area designated in writing by the fire safety expert. The one individual who refused to evacuate in the required, extended time has been and will continue to be retrained regarding evacuation requirements. This training is ongoing and documented by residential staff. Program Specialist will continue to monitor for compliance. 06/18/2018 Implemented
SIN-00120332 Renewal 08/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected in this residence on 2/1/2016. It was not inspected again until 2/26/2017, which exceeds the annual requirement.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. 55 PA Code 6400.106 - All required furnace cleanings will be completed/documented annually within the required time frame. Director of Operations will monitor/document cleanings 08/29/2017 Implemented
6400.112(d)On 7/24/2017, a sleep fire drill was held at 11:00PM. The evacuation time for this drill was 3 minutes & 16 seconds, which exceeds the requirement by 46 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 55 PA Code Chapter 6400.112(d) - On 7/31/17 Fire Marshall reassessed evacuation time needed and increased the time required to 3 min. 30 sec. for home evacuation. All drills will be documented to insure evacuation occurs within the allotted time frame. Program Specialist will be responsible for documentation review. 07/31/2017 Implemented
6400.181(e)(4)This area was not evaluated in Individual #2's assessment. The assessment must include the following information: The individual's need for supervision. 55 PA Code Chapter 6400.181(e)(4) - Need for supervision is currently identified throughout assessment; however, a specific section will be added to identify need for supervision. Program Specialist will add this section to all assessments. 10/02/2017 Implemented
6400.181(e)(13)(viii)This area was not evaluated in Individual #2's assessment.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. 55 PA Code Chapter 6400.181(13)(viii) Managing personal property section will be added to all assessments. Program Specialist will be responsible to add this section to all assessments. 10/02/2017 Implemented
SIN-00099861 Renewal 08/16/2016 Compliant - Finalized
SIN-00080024 Renewal 07/21/2015 Compliant - Finalized
SIN-00061739 Renewal 05/06/2014 Compliant - Finalized
SIN-00050018 Renewal 04/16/2013 Compliant - Finalized