Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261980 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Based upon the expiration of the certificate of compliance the self-inspection of the home should have been completed between 9/4/24 and 1/4/25. The self-inspection submitted for review was completed on 2/4/25.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. This reg. is important to measure the record of compliance with the chapter When I got the instructions about doing self-assessment between the date of the letter to the date of the inspection, I only presented the current one to the inspector. Even though I did the previous one in November and December of 2024. I was requested to give self-assessment, and I only gave the current one done in Jan. and Feb. of 2025 03/06/2025 Implemented
6400.66The exit to the outside of the home from the basement did not have any lighting at the time of inspection. The egress route from the basement consists of an interior door a small room and then the exterior door. The doors are well below normal height with the transition area being approximately five feet high with beams and ventilation tubing on the ceiling. The egress area presented hazards and was not illuminated.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Lighting is important to ensure safe passage in case of fire emergency During the inspection, the basement had a small egress area that was not illuminated enough. This was reported to the landlord, and they are working on putting another light there. 03/26/2025 Implemented
6400.80(b)At the time of inspection, a pile of leaves were noted to be alongside of the home and extending over the direct path to the gate to the front of the home. The pile of leaves varied in height with the tallest approximately four feet. The leaves extended approximately eight feet into the yard and covered approximately six feet of the direct path to the gate. The grounds of the home shall be free from unsafe conditions. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.It is important that the yard and all the surroundings for health and safety. During the inspection, there was pile of leaves on the side of the house. Maintenance swept the leaves to get rid of it but were not able to finish the job in one day. 03/07/2025 Implemented
6400.141(c)(13)The section designated for allergies on the physical dated 12/10/24 was blank. Allergy information was not found on the physical form.The physical examination shall include: Allergies or contraindicated medications.Individual physical examination is important to properly document all medical information The 12/10/24 physical examination for allergies section was left blank. The physical was returned to the doctor¿s office twice for correction, the 2nd time staff was told the doctor went on vacation and none of the nurses there would do anything about it. 03/16/2025 Implemented
6400.144At time of inspection the March 2025 Medication Administration Record (MAR) for Individual #1 contained entries for Cepacol throat lozenges to be administered as needed. There was no Cepacol in the home. The March 2025 MAR for Individual #1 also contained an entry for Motrin to be given as needed. There was no Motrin in the home at time of inspection.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. Individual health is essential, and all medications on MAR should be present in the home. At the time of the inspection, Motrin-PRN and Cepacol throat lozenges-PRN were on the MAR but not in the home. When staff called to refill the medications because they were about to expire, they were told that the medications were discontinued. However, for us to DC med, we must have the DC order written by the prescriber or from the pharmacy. We did not get any of that. We reached out to the doctor again for refill and we were told they would when they got the doctor. So, we did not get the refill until after the inspection. 03/21/2025 Implemented
6400.151(a)A hire date of 12/9/24 was provided for Staff #2. The physical for Staff #2 was documented as completed on 12/16/24. Staff person shall have a physical examination within 12 months prior to employment A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Per the reg. staff should have their physical examination done within 12 months prior employment. Doing the time of the inspection, a staff member physical exam was done after their hire date. The staff did their physical exam before they interacted with the individual, however their hire date was input based on the date of their background check. 03/21/2025 Implemented
6400.46(a)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records provided indicate that Staff #2 had fire safety training on 1/22/25. This is outside of the regulatory timeframes.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.This reg. is important in training staff in fire safety before they can work with the individual. In case of fire emergency, they will know how to respond. The fire safety training date was after the hire date of the staff person. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. 03/07/2025 Implemented
6400.51(b)(1)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records indicate that training on individual choice and supporting individuals to develop and maintain relationships was completed on 1/21/25. Training records indicate that training on application of person-centered practices was completed on 1/16/25 and 1/21/25. Trainings were completed outside of the regulatory timeframe.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Training Reg is important and should be done within the timeframe. The staff member training date was outside of the training timeframe stipulated by the regulations. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. 03/07/2025 Implemented
6400.51(b)(2)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records indicate that training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act was completed on 1/16/25. This is outside of the regulatory timeframe.The orientation 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.Training Reg is important and should be done within the timeframe. The staff member training date was outside of the training timeframe stipulated by the regulations. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. 03/07/2025 Implemented
6400.51(b)(3)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records indicate that training on Individual rights was completed on 1/16/25. This is outside of the regulatory timeframe.The orientation must encompass the following areas: Individual rights.Training Reg is important and should be done within the timeframe. The staff member training date was outside of the training timeframe stipulated by the regulations. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. 03/07/2025 Implemented
6400.51(b)(4)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records indicate that training on recognizing and reporting incidents was completed on 1/20/25 and 1/23/25. This is outside of the regulatory timeframe.The orientation must encompass the following areas: recognizing and reporting incidents.Training Reg is important and should be done within the timeframe. The staff member training date was outside of the training timeframe stipulated by the regulations. This was an administrative error by using the criminal background check dates as a hire date. All our staff are trained before they work with our individuals. 03/07/2025 Implemented
6400.51(b)(5)Staff #2 has a documented hire date of 12/9/24 and a first day or working with individuals date of 1/17/25. Training records indicate that training on the Individual Support Plan (ISP) for Individual #1 did not occur until 1/20/25. Training on the ISP is essential knowledge that is required prior to working with Individuals.The orientation must encompass the following areas: Job-related knowledge and skills.Training Reg is important and should be done within the timeframe. The staff member ISP training date was outside of the training timeframe stipulated by the regulations. This was the trainer¿s error by not signing on the date the training was done. Instead, he signed a date after the training was done. 03/07/2025 Implemented
6400.52(c)(1)Staff #1 had a documented hire date of 8/18/22. Training records did not include a record of training on community integration, individual choice and supporting individuals to develop and maintain relationships as required.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.Training is important to maintain quality support for the individual. At the time of the inspection, Staff #1 who were hired 8/18/22 training records did not include individual choice training. Staff #1 did all the required training with additional training. Individual choice and relationship are covered under the Individual Right and person center training which were done. Staff were not aware that the training must be done separate. 03/21/2025 Implemented
6400.163(h)Individual #1 was prescribed Derma-Smoothe-FS-Body Oil. The pharmacy label indicates that the medication was filled on 1/17/25 and was to be administered as "Apply a few drops to aff. area(s) on scalp 2x daily as needed (eczema) X 2 weeks. At the time of inspection on 3/5/25 the medication remained in the home. The medication should have been discarded by 2/1/25.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired or D/C medications could cause a serious injury or death, it is important all meds are properly checking the safe administration. At the time of the inspection, a discontinued med was located among the individual medications. The med was administered for two weeks and should have been removed and sent to the pharmacy. The supervisor assured the nurse that she returned it to the pharmacy. Later a staff member said that the pharmacy returned the med back to the home thinking it was they made an error sending the med back to the pharmacy. It was removed and again returned to the pharmacy. 03/19/2025 Implemented
6400.166(a)(8)At time of inspection the March 2025 Medication Administration Record (MAR) recorded an entry for Derma-Smoothe-FS Body Oil Fluocinolone. Administration directions were listed as "If using in the same area, take 1 week break, may restart if needed. The MAR did not note the route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual health is essential, and all medications on MAR should have a clear direction. At the time of the inspection, Derma-Smoothe-FS body oil did not have a direct route of administration. The Doctor said the direction was clear including the route. And did not want to rewrite anything. It was supposed to be one prescription, but the pharmacy wrote it twice. 03/26/2025 Implemented
6400.166(a)(9)At time of inspection the March 2025 Medication Administration Record (MAR) recorded an entry for Derma-Smoothe-FS Body Oil Fluocinolone. Administration directions were listed as "If using in the same area, take 1 week break, may restart if needed. The MAR did not note the frequency of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual health is essential, and all medications on MAR should have a clear direction. At the time of the inspection, Derma-Smoothe-FS body oil did not indicate how often the medication should be administrated. The Doctor said the direction was clear including the route. And did not want to rewrite anything. It was supposed to be one prescription, but the pharmacy wrote it twice. 03/25/2025 Implemented
6400.186Individual #1 has a restrictive procedure plan (RPP) in place that was last updated on 11/28/24. At time of inspection, it was noted that the RPP was not being implemented as written. The RPP indicates that Individual #1 should "not be allowed to touch or hold the mail from the mailbox." Staff #3 noted that Individual #1 is allowed to "get the mail" then "gives it to staff." The RPP indicates that Individual #1 is restricted in phone usage and "staff will inquire who [they] will contact, and [they] will inform staff of who [they] will contact before [they] do so. "The phone must remain on the speaker throughout the call. Direct staff supervision is required throughout the entirety of the call." Staff #3 reported that Individual #1 "uses the phone as she wants" and "can make and receive calls independently."The home shall implement the individual plan, including revisions.This regulation is important to keep the team informed about the progress and growth of the individual, and changes in behavior. At the time of the inspection, the individual RPP was not being implemented. The staff person was recently hired and trained in on the individual RPP. The staff demonstrated her incompetency. 03/26/2025 Implemented