Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253362 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed from 9/11-12/24.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. CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. 12/31/2024 Implemented
6400.64(a)At 10:31 AM a fourteen-inch, thick cobweb with deceased spiders and other insects was found attached to the inside of the screen in the window to the left of Individual #1's bed.Clean and sanitary conditions shall be maintained in the home. Bedroom window and screen were cleaned. 12/31/2024 Implemented
6400.64(e)At 10:18 AM on 9/26/24, a trash receptacle, measuring greater than eighteen inches high, was found without a lid containing various items of trash and located next to the door inside the garage of the home.Trash receptacles over 18 inches high shall have lids. Garbage can has been removed. 12/31/2024 Implemented
6400.82(e)At 10:15 AM on 9/26/24, there was no nonslip mat observed in the bathroom off the home's main hallway. Bathtubs and showers shall have a nonslip surface or mat. Non Slip decals were placed in the bathtub. 12/31/2024 Implemented
6400.101At 10:20 AM on 9/26/24, a cooler and chair were found on the back deck of the home, directly in front of the exit door leading from the hallway next to the home's garage, causing an obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The cooler and chair were removed so that there is unobstructed egress. 12/31/2024 Implemented
6400.107At 10:40 AM on 9/26/24, the television stand in the left corner of the home's living room had an attached space heater.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The space heater has been removed from the home. 12/31/2024 Implemented
6400.112(a)According to the written fire drill record from October 2023 to August 2024, there were no unannounced drills conducted at the home from October 2023 through December 2023. An unannounced fire drill shall be held at least once a month. Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated and reviewed with all residential homes managers on 10/3/2024. 12/31/2024 Implemented
6400.181(e)(1)Individual #1's assessment, completed on 9/9/24, did not include their functional strengths, needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. CLASS annual assessment has been revised to add Functional strengths, needs and preferences of the individual. 12/31/2024 Implemented
6400.15(b)The agency completed the home's self-assessment from 9/11-12/24. The following violations were identified with no written summary of corrections: .20b, .34a, .112a, .112b, .112c, .112d, .112e, .112f, .112g, .112h, .112i, .141c4, .141d, .142a, .142b, .142c, .142d, .165a and .213(4).(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. 12/31/2024 Implemented
6400.32(r)(1)At 10:23AM on 9/26/2024, Individual #1's bedroom door was equipped with a pinhole lock. Interviews revealed that Individual #1 did not have a designated mechanism to lock and unlock the door. At 10:25 AM on 9/26/24, Individual #2's bedroom door was equipped with a pinhole lock. Interviews revealed that Individual #2 did not have a designated mechanism to lock and unlock the door. At 10:26 AM on 9/26/24, Individual #3's bedroom door was equipped with a pinhole lock. Interviews revealed that Individual #3 did not have a designated mechanism to lock and unlock the door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Locks were changed to straight locks on bedroom doors. 12/31/2024 Implemented
6400.32(r)(5)At 10:23 AM on 9/26/24, Individual #1's bedroom door was equipped with a pinhole lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 10:25 AM on 9/26/24, Individual #2's bedroom door was equipped with a pinhole lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 10:26 AM on 9/26/24, Individual #3's bedroom door was equipped with a pinhole lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Locks were changed to straight locks on bedroom doors. 12/31/2024 Implemented
6400.52(b)(1)Chief Executive Officer #1 completed 2.5 hours of trainings during the 2023-2024 fiscal training year.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.CEO has completed required training. 12/31/2024 Implemented
6400.52(c)(2)Chief Executive Officer #1's trainings for the 2023-2024 fiscal training year did not include the application of person-centered practices.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.CEO has completed required training. 12/31/2024 Implemented
6400.52(c)(2)Chief Executive Officer #1's trainings for the for the 2023-2024 fiscal training year did not include the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse.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.CEO has completed required training. 12/31/2024 Implemented
6400.52(c)(3)Chief Executive Officer #1's trainings for the 2023-2024 fiscal training year did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.CEO has completed required training. 12/31/2024 Implemented
6400.52(c)(4)Chief Executive Officer #1's trainings for the 2023-2024 fiscal training year did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.CEO has completed required training. 12/31/2024 Implemented
6400.163(a)At 10:48 AM on 9/26/24, Individual #1's prescribed controlled medications, Nayzilam, Xcorpi 200 MG and Clobazam 10 MG, were stored in a single-locked cabinet in the dining room of the home.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.All controlled medications are now double locked. Lock boxes were ordered and given to each person who required them. 12/31/2024 Implemented
6400.166(b)Individual #1's September 2024 Medication Administration Record showed the following: their prescribed 8 AM medications were not initialed as administered on 9/6/24; and their prescribed 8 PM medications were not initialed as administered on 9/11/24 and 9/13/24. Additionally, on 9/26/24 at 8 AM, Individual #1's prescribed dose of Ferosul 325 MG Tablets, was initialed as administered. However, interviews revealed that the medication was not present at the home and was not administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Program specialist reviewed the MAR and the blister pack and determined that this was documentation error. Program specialist determined that medication was given correctly. 12/31/2024 Implemented
6400.167(a)(1)Individual #1 is prescribed Ferosul 325MG with instructions to, "Take 1 tablet by mouth every other day for iron supplement." Interviews revealed that this medication was not administered as prescribed at 8 AM on 9/26/24.Medication errors include the following: Failure to administer a medication.A medication error was entered into EIM for this incident. 12/31/2024 Implemented
SIN-00232943 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)Individual #1's physical examination completed on 01/31/23 did not address the physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Residential homes managers will be retrained on the importance of physical exam forms being completed appropriately prior to leaving annual physical appointments. 10/27/2023 Implemented
SIN-00213556 Renewal 10/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171At 11:49AM on October 20, 2022, there was a gallon of milk in the refrigerator with an expiration date of October 4, 2022, and there was a carton of eggs with an expiration date of October 14, 2022.Food shall be protected from contamination while being stored, prepared, transported and served. Items that were expired were discarded at the time of the inspection on 10/20/2022. 11/22/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 5/5/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Old versions of the self-assessment tool were shredded and discarded. Staff were asked to complete the self-assessment on the correct version this will be completed by 11/22/2022 The correct version of the Self Assessment Tool was sought out by new Quality and Compliance Coordinator and supplied by inspector. All expired versions of the Self Assessment Tools were erased off the internal databases by Quality and Compliance Coordinator. Updated version was placed on internal site by direction of IT 11/22/2022 Implemented
6400.165(c)Individual #1's October 2022 Medication Administration Record lists Nystatin as "PRN" (pro re nata) and the medication label states, "apply topically two times a day." Individual #1's October 2022 Medication Administration Record lists Clotrimazole as "PRN" (pro re nata) and the medication label states, "apply to scaling areas on face and ears 1-2 times daily."A prescription medication shall be administered as prescribed.The MAR at 808 Cranberry was corrected by the Residential House Manager to match the prescription label. 12/19/2022 Implemented
SIN-00196556 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home.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. The Senior Residential Homes Managers will complete the self-assessment of their assigned homes by December 20, 2021. The Residential Director will review each plan prior to submission. 12/20/2021 Implemented
SIN-00121256 Renewal 09/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Direct Service Worker #1 had fire safety training 7/18/16 then again 7/23/17.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). CLASS's Training Coordinator will construct a spreadsheet to track all residential staffs' annual fire safety training in the effort to insure that said training is conducted within the 365 day timeframe. Regarding the individuals supported by CLASS's residential program, the assigned Program Specialist will be responsible to track this training and insure it occurs within the 365 day timeframe.[At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure Program specialists and direct service workers are trained annually by a fire safety expert in the training areas specified in subsection (f). Documentation of audits shall be kept. (AS 10/4/17)] 10/31/2017 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was 2/22/17.A fire drill shall be held during sleeping hours at least every 6 months. All direct support staff will be retrained by the assigned Residential Homes Specialist in the proper completion of unannounced fire drills including the annual timeframe in which asleep fire drills must be completed.[Within 15 days of receipt of the plan of correction, a fire drill during sleep hours shall be held and documented as required. At least monthly for 6 months and continuing at least quarterly, upon completion of a fire drill, the CEO or designee shall audit the all fire drill documentation to ensure the fire drill is completed and documented as required and there are not any areas of required information left blank on the fire drill record. Documentation of audits and aforementioned trainings shall be kept. (AS 10/4/17)] 10/31/2017 Implemented
6400.112(g)The monthly fire drills from held during awake hours from 8/2016 to 8/2017 were between 3:30PM and 6:30PM. Three fire drills held during sleeping hours from 8/2016 to 8/2017 were between 4:30AM and 5:00AM. Fire drills shall be held on different days of the week and at different times of the day and night. All staff will be retrained by the assigned Residential Homes Specialist in the proper completion of unannounced fire drills including the requirement to vary days and times of these drills.[At least monthly for 6 months and continuing at least quarterly, upon completion of a fire drill, the CEO or designee shall audit the all fire drill documentation to ensure the fire drill is completed and documented as required and there are not any areas of required information left blank on the fire drill record. Documentation of audits and aforementioned trainings shall be kept. (AS 10/4/17)] 10/31/2017 Implemented
6400.112(i)The home is using a smoke detector which is not part of the home's fire alarm system to conduct fire drills. A fire alarm or smoke detector shall be set off during each fire drill.All staff will be trained by the assigned Residential Homes Specialist in the conduction of monthly fire drills using the current operating fire system (integrated or individually mounted smoke detectors).[Documentation of the training shall be kept. At least quarterly for 1 year, a residential home specialist(s) shall observe a fire drill at each community home to ensure fire drills are conducted as required as per 6400.112(a)-(I) to ensure the safety of the individuals. (AS 10/4/17)] 10/31/2017 Implemented
6400.141(c)(8)Individual #1, date of birth 8/14/52, had a mammogram on 10/14/15 then again 11/10/16.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. A chart indicating the last and next required dates for all annual appointments including the mammogram for female consumers was created by the assigned Residential Homes Specialist Assistant and will be used to insure that appointments are scheduled within the designated timeframe. The Quality Compliance and Privacy Officer and/or assigned Associate Director will audit this information periodically during the year to insure compliance with this regulation. [Aforementioned audits shall be conducted at least quarterly. Documentation of audits shall be kept. (AS 10/4/17)] 10/06/2017 Implemented
6400.181(f)The program specialist indicated Individual #1's assessment, completed 5/1/17 was sent to interdisciplinary team on 6/7/17, the plan team members were not identified; therefore, compliance could not be measured.(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). Effective immediately, the assigned Program Specialist will retain proof of the provision of each individual(s) assessment either by keeping the letter and dated envelope for each member of the IDT or the email listing all members with the attached assessment at least 30 days prior to the meeting date. [At least quarterly for 1 year, the CEO or designee shall audit 25% sample of correspondence documentation showing the program specialist provided all individuals' assessments to all plan team members as required, timely. Documentation of audits shall be kept. (AS 10/4/17)] 10/06/2017 Implemented
6400.186(b)The Program Specialist's name was typed in place of the signature on Individual #1's ISP reviews, dated 10/12/16 and 1/12/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Effective immediately the ISP reviews will be manually signed by the appropriate Program Specialist. In addition, all previously electronically signed ISP reviews will be corrected with a live signature written beside or above the typed signature.[Immediately, the CEO or designee shall review with all program specialist(s) the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall review a 25% sample of individuals' ISP reviews to ensure the program specialist sign and date the individuals' ISP reviews as required. (AS 10/4/17)] 10/13/2017 Implemented
SIN-00101157 Renewal 09/23/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 3/27/16 had an evacuation time of 3 minutes and 10 seconds. There is not an extended evacuation time specified in writing by a fire safety expert. [Repeated Violation 8/27/15 et al.] 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. Fire drill records prior to and since the 3/27/16 drill all show the individuals evacuating the house in less than 2 and 1/2 minutes. The staff conducting the 3/27/16 fire drill gave no explanation of the reason for the delay and the individual does not recall the reason either. To avoid a lengthy evacuation in the future, individual MPV was counseled by the Residential Homes Manager regarding the importance of responding to a fire alarm when it goes off. She demonstrated an understanding of this issue and agreed to be cooperative and do her best to evacuate effectively at all times. Fire drills will continue to be monitored monthly by the Residential Homes Manager and if a pattern is detected of drills over 2 and 1/2 minutes, an alternative plan will be developed. [Immediately, the CRO will review the fire drill documentation along with 6400.112(A)-(I) and revise as needed to ensure accurate documentation of fire drills. Within 30 days of receipt of the plan of correction, the CRO will develop and implement policies and procedures to ensure fire drills are conducted and documented as require including evacuating in less than 2 and 1/2 minutes and procedures to follow if required evacuation time is not met. Within 30 days and continuing at least quarterly for 1 year all staff persons shall be trained in aforementioned policies and procedures. Within 60 days of receipt of the plan of correction, a program specialist(s) shall observe a fire drill at each community home to ensure an unannounced fire drill is completed and documented as required. At least quarterly, the CEO or designated management staff shall review all fire drill records to ensure fire drills are conducted and documented as required. Documentation of trainings and monthly and quarterly reviews of all fire drills shall be kept. (AS 11/7/16)] 10/13/2016 Implemented
6400.163(c)Individual #1's psychotropic medications were reviewed by a physician on 11/11/15 and then again on 3/10/16. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Psychotropic medication review procedures were reviewed with the assigned Community Support Coordinator on 10/11/16 to ensure that 3 month reviews of these medications are reviewed quarterly by a licensed physician. In addition a section was added to the health report form specific to psychotropic medication quarterly checks for licensed physician to complete and sign. [Immediately, the CRO and associate director shall develop and implement a tracking and a review process to ensure timely medication review completion to include scheduling advanced appointments to ensure timely completion with all required information. All staff persons shall be trained in their responsibilities to ensure timely and accurate completion of medication reviews. At least quarterly for 1 year the CRO or Associate director shall review medication reviews to ensure timely completion and review and revise procedures if need. Documentation of training, tracking and reviews shall be kept. (AS 11/7/16)] 10/13/2016 Implemented
SIN-00083441 Renewal 08/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The evacuation time for the fire drill conducted on 7/26/15 was 3 minutes and 1 second. The home does not have an extended evacuation time in writing by a fire safey expert. 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. Residential Homes Manager is to deliver a letter to the local fire department which indicates the longest amount of time evacuation takes for this home. If deemed an appropriate length of time, a fire company representative will be asked to sign a letter stating their approval. This letter will be filed in the fire drill log book. This process will be repeated annually if evacuation times are over two and a half minutes. [A fire safety expert is to determine the extended evacuation time in writing. A letter, dated 11/6/15 was submitted to the department on 12/8/15 from The Building Inspector of Municipality who; in short, did not commit to an evacuation exact time but did write "it is my opinion that using a maximum benchmark time of three minutes for total evacuation is a viable goal in order to provide the residents a realistic chance of safety and survival during an emergency at the facilities." The CEO will continue to monitor the fire drill records to ensure Individuals evacuate in the specified times. In addition, CEO or designee will work with individuals to provide education and skills to aid in safe evacuation not to exceed the time specified in writing by a fire safety expert yearly or within 2 and 1/2 minutes. (AS 12/23/15)] 10/01/2015 Implemented
6400.151(a)The two most recent physicals examinations for Direct Support Staff #1 were completed on 12/30/2014 and 8/17/2012. 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. CLASS's residential program's office manager will provide each Residential Homes Manager a monthly chart that includes due dates for staff physicals and TB tests. It is the responsibility of the RHM to remind staff of this requirement and provide them with the agency's form. In addition the office manager will send via the RHMs a quarterly letter which will also indicate the due date for this area[As per conversation with CEO 10/23/15, Once employee or Residential manager gives the office manager the completed physical examination, the office manager will review the physical examination documentation form and either return form for completion or file completed form in the employee record. (AS 10/23/15)] 10/03/2015 Implemented
6400.181(f)The assessment for Individual # 1, dated 6/1/15, was not provided to the team members 30 days prior to the ISP Meeting which was held on 7/16/15.(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). Program Specialist will send assessment summaries to all team members at least 30 days prior to the annual meeting dates based on the prior years' schedule beginning immediately.[As per conversation with CEO on 10/23/15, CEO conducted a 15 minute in-service for the program specialists on the process to maintain documentation of what was sent to team members. PS will review invitation letter and ISP to ensure all team members receive the assessments and ISP reviews for all individuals. CEO will review a 25 % sample of individuals' records at least monthly for the next 6 months to ensure assessments and ISP reviews are being sent and documentation is being maintained in the individuals' records as required. (AS 10/23/15)] 10/03/2015 Implemented
6400.186(d)The ISP review documents for Individual #1 dated 10/23/14, 1/23/15, 4/23/15 and 7/16/15 were not sent to plan team members. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Assigned Program Specialist was reinstructed on this requirement and will ensure that other team members, including the SC, are provided with ISP review documentation beginning immediately.[As per conversation with CEO on 10/23/15, CEO conducted a 15 minute in-service for the program specialists on the process to maintain documentation of what was sent to team members. PS will review invitation letter and ISP to ensure all team members receive the assessments and ISP reviews for all individuals. CEO will review a 25 % sample of individuals' records at least monthly for the next 6 months to ensure assessments and ISP reviews are being sent and documentation is being maintained in the individuals' records as required. (AS 10/23/15)] 10/03/2015 Implemented
SIN-00160393 Renewal 08/08/2019 Compliant - Finalized
SIN-00140418 Renewal 08/21/2018 Compliant - Finalized
SIN-00098041 Unannounced Monitoring 06/10/2016 Compliant - Finalized
SIN-00088583 Unannounced Monitoring 12/03/2015 Compliant - Finalized