Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257466 Renewal 12/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the home was tested and found to be 149 degrees. [REPEAT VIOLATION] Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance was sent to the home on 12/17/2024 to turn down the temperature on the boiler. Scheduled conferences were had with DSP Supervisors on 12/19/2024 and a monthly water temperature log was implemented for monthly reviews of water temperatures. 12/24/2024 Implemented
6400.110(e)The third-floor smoke detector was not connected and therefore did not go off during the check. It did however work separately.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The Program Specialist purchased new fire alarms and they were interconnected in the office by the Director prior to being installed in the home on 12/24/2024 by maintenance. Conferences were had with the supervisors on 12/19/2024 to review that all smoke detectors should be interconnected with one another. On 12/20/2024 DSP¿s who work in the home and complete fire drills participated in conferences to explain that all fire alarms should be interconnected, meaning working simultaneously during fire drills and if not then maintenance will be scheduled to adjust within 24-hours of identification. 12/24/2024 Implemented
6400.141(c)(14)Individual 1's annual physical exam did not address medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 12/19/2024 conferences were held with supervisors to review the 6400.141c regulation pertaining to medical information that physical exams should maintain pertinent to diagnosis and treatment in case of an emergency and the program specialist accompanying individuals and staff to all annual physical appointments to ensure all medical records are completely fully and accurately by overseeing providers. On 12/20/2024 conferences were held with staff to review the new policy and to ensure program specialists were informed of the changes in policy to ensure all medical records are completely fully and accurately. 12/24/2024 Implemented
6400.216(a)There were individual records unlocked in the dining room of the home. An individual's records shall be kept locked when unattended. Locks were purchased by the supervisor for cabinets to lock up individual records and maintenance installed the locks. Conferences were held with all program specialists and supervisors on 12/19/2024 to review the required regulations. In-service for all DSPs were held on 12/20/2024 to review the policy of locking up individual records when not in use and/or when away from the home. 12/24/2024 Implemented
6400.24The 03/01/24 Room and Board Residency Agreement has individual 1 paying $1,185.84 for room and board and the 04/27/23 Room and Board Residency Agreement has the individual paying $1,319.76. The individual's share of room and board may not exceed 72% of the SSI maximum rate ($943.00) plus the Pennsylvania supplement ($22.10) which is 72% of $965.10 or $694.87. § 6100.686. Room and board rate. (a) If the actual provider room and board cost as specified in § 6100.684 (relating to actual provider room and board cost), less any benefits as specified in § 6100.685 (relating to benefits), is more than 72% of the SSI maximum rate plus the Pennsylvania supplement, the following criteria shall be used to establish the room and board rate: (1) An individual's share of room and board may not exceed 72% of the SSI maximum rate plus the Pennsylvania supplement.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.An updated Room and Board agreement was signed with the individual by the CFO, and the cost was recalculated (exhibit 5). A conference was held with the CFO and supervisors on 12/19/2024 to review the 6400.24 regulation that room and board should not exceed 72% of the SSI max rate plus supplemental. Overpayment funds returned to the individual. 12/24/2024 Implemented
SIN-00215905 Renewal 12/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The oven, stove top and ventilation hood need a thorough cleaning and degreasingClean and sanitary conditions shall be maintained in the home. The CEO scheduled a house deep cleaning provided by a third-party cleaning agency on 1/20/2023 to ensure clean and sanity conditions of the home. All current staff were retrained on house cleaning and sanitation (see exhibit B). New weekly cleaning log developed and utilized for all shift responsibilities which will be tracked by the house supervisor to ensure compliance (Exhibit C) 01/20/2023 Implemented
6400.67(b)The middle vacant bedroom has a plumbing access panel in the closet that is not securely affixed to the wall. Floors, walls, ceilings and other surfaces shall be free of hazards.On 1/3/2023 The plumbing access panel was affixed to the wall by a third-party contracting company - All In One Construction Company to ensure all floors walls, ceilings and all surfaces are from from hazards. 01/20/2023 Implemented
6400.71The dining room phone does not have emergency numbers nearby. The emergency phone numbers for this home and all this providers home are located inside a binder that is not necessarily near the telephone. The emergency numbers were placed near the phone prior to the end of the inspection.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. On 12/23/2022, The CEO secured emergency phone numbers to the wall by the phone to ensure they are not misplaced away from the phone. All current staff were retrained on the agency policy and Chapter 6400.71 regulations of maintaining emergency contact information by the phone (see attached exhibit B). 12/23/2022 Implemented
6400.82(f)The basement bathroom does not include a sink, paper towels, wastebasket, or soap.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. Due to the bathroom in the basement not containing a sink currently, the bathroom was locked on 12/23/2022 by the CEO and the key will be kept at the main office to ensure it is inaccessible by anyone until a sink can be installed. 12/23/2022 Implemented
6400.112(e)Asleep drill is not indicated on the forms.A fire drill shall be held during sleeping hours at least every 6 months. The CEO developed a new fire drill form to include the date, time, meeting location and all members involved in the fire drill (See exhibit D). Staff were retrained on utilizing the new form and capturing all information (see attached training sing-in sheet). 01/20/2023 Implemented
6400.112(h)There is no meeting place designation indicated on the fire drill logs Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The CEO developed a new fire drill form to include the date, time, meeting location and all members involved in the fire drill (See exhibit D). Staff were retrained on utilizing the new form and capturing all information (see attached training sing-in sheet). 01/20/2023 Implemented
6400.181(e)(14)The Assessment does not include individual number 1 ability to swim in water safely.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.On 1/5/2023, the CEO retrained the Program Specialist and house supervisor on documenting each individual's knowledge of water safety and ability to swim on the annual assessment (See exhibit E). 01/05/2023 Implemented
SIN-00198411 Renewal 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguishers in the home did not have current inspection tags. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. To ensure compliance with 55PA Code Chapter 6400.111 - annual fire extinguisher inspection and fire safety, the Program Specialist scheduled and completed the inspection for the fire extinguishers within the home. Current inspection tags were placed on each fire extinguisher within the home. 01/13/2022 Implemented