Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270078 Renewal 08/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Individuals did not evacuate the home in at least 2 ½ minutes on 2/16/25. The fire drill completed on 2/16/25 was completed in 7 minutes and 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. This was an error of completion. Staff were retrained on proper fire drill SOP. 09/30/2025 Implemented
6400.141(c)(9)Individual #1 is 65 years old and has not had an annual prostate exam completed.The physical examination shall include: A prostate examination for men 40 years of age or older. New Case manager was hired on 3/3/25 and will be training and following up on medical appointment issues. 10/31/2025 Implemented
6400.143(a)Individual #1 missed a vision appointment on 6/24/25. Documentation indicated that individual #1 wanted to go to work instead of the appointment. There was no documentation providing continued attempts to trained and education Individual #1 on the importance of attending medical appointments.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. New case manager was given education on how to complete the forms for missed appointments. 09/30/2025 Implemented
6400.144Health services including completion of Cologuard testing were not planned for or arranged. Individual #1 was ordered to complete Cologuard testing on 5/14/24. There was no documentation that this was completed.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. New Case Manager was hired on 3/3/25 and will be trained and correcting all previous errors. All appointments have been scheduled for the next possible appointment. 10/31/2025 Implemented
6400.151(a)Staff #1 did not complete a physical examination every two years. Staff #1 completed a physical examination on 12/14/23 and did not complete another until 1/9/25. 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. Staff will be retrainined on the importance of completing physicals when assigned. 08/31/2025 Implemented
6400.52(c)(3)Staff #1 did not complete annual training in individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Training of individual rights was completed prior to the next shift. 10/31/2025 Implemented
6400.163(a)Prescription medications do not have pharmacy labels. Individual #1 is prescribed Cleocin Pads. The container with the medication was missing half of the pharmacy label.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.A new label was printed and applied to the medication. 09/06/2025 Implemented
6400.165(g)Individual #1 did not have a review of medications prescribed to treat symptoms psychiatric illness completed at least every three months. Individual #1 had a review of psychotropic medications completed on 9/27/24, 2/26/25 and 3/26/25. These reviews did not include all of the required documentation including the reason for prescribing the medication, the need to continue the medication and the necessary dosage.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.Another psychiatric appointment was already completed in August for this individual. 09/30/2025 Implemented
6400.166(b)Individual #1 is prescribed Nizoral and Cleocin Pads to be administered at 8PM. The Medication Administration Record (MAR) did not include staff initials on 8/3, 8/6 and 8/8 at 8PM. Individual #1 is prescribed Refresh Liquid gel at 8am, 4pm and 8pm. The MAR did not include staff initials on 8/5 at 4pm, 8/7 at 4pm, 8/8 at 8pm, and 8/9 and 8/10 at 4pm.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff retraining and a meeting scheduled with the pharmacy to ensure that there are no further issues with medical reordering. 12/31/2025 Implemented
6400.169(a)Staff #1 did not complete the renewal requirements of a department-approved medication administration course. Staff #1 was documented as completing the renewal requirements of a department approved medication administration course on 1/10/25, however the observations in the renewal course were not completed within 6 months of as required. Observations were documented as completed in 6/24 and 1/25.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Three additional Practicum Observers had the course completed right before Licensing and will be completing additional observations. 12/31/2025 Implemented
SIN-00227403 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 was hired on 8/9/2019, and Staff #1's criminal history check was not completed until 8/15/19. Staff #1 did not have a criminal history check completed within five days of hire.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. New ADP workforce Now contract will keep track of all criminal histories, physicals, and TB tests to ensure compliance with regulations. 01/01/2023 Implemented
6400.112(c)The fire drill completed on 6/21/23 did not include an evacuation time.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23) Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23. 08/15/2023 Implemented
6400.141(c)(6)Individual #1's physical exam dated 4/4/23 (form indicated that exam took place on 1/5/23 and the form was sent to the physician to be completed on 4/4/23) did not include a tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.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. Intake physicals will be reviewed in a Team meeting prior to admission beginning 8/1/23 and ongoing. Incomplete physicals will not be admitted to the program until it is completed, no exceptions. 08/01/2023 Implemented
6400.142(f)Individual #1 did not have a dental hygiene plan.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Client services called all dentists on record and received recommendations (8/1/23) 08/15/2023 Implemented
6400.181(e)(6)Individual #1's initial assessment dated 4/26/23 did not assess the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Poison Safety question was added retroactively to all 2022/2023 Annual Assessments. 07/24/2023 Implemented
6400.165(c)Medications are not administered as prescribed. Individual #1 is prescribed Azelastine 0.1% (137mcg) spray. This medication is prescribed for seasonal allergies. This medication was filled on May 4, 2023. Inhale 1-2 sprays in each nostril twice daily directed. The medication bottle contained 200 metered sprays. At the time of the inspection the bottle contained more than half a bottle in the home. The medication is documented as administered as prescribed on the Medication Administration Record.A prescription medication shall be administered as prescribed.Individuals who are capable to self-administration of topical and nasal sprays will be evaluated for self-administration beginning 8/31/23 and ongoing. HCQU will review the correct usage of topicals, drops, and sprays in the training on 8/16/23. This training will be requested Annually from the HCQU. 08/31/2023 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. These medications were reviewed by a licensed physician on 4/18/23, 5/16/23, and 6/20/23 the form used did not include the necessary dosage of 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.Medication lists will be attached to all psych notes for physician review and available when viewed in the scanned BOX paperwork (7/19/23 and ongoing) Medical note updated to reflect Psychiatric med review of medications and the symptoms requiring ongoing treatment. 07/21/2023 Implemented
SIN-00180194 Renewal 12/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Each bathroom and toilet area that is used shall have a sink, wall mirror, soap and toilet paper, individual clean paper towels or cloth towel and trash basket. The bathroom on first floor and second floor of the home did not have 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. Staff did not replenish supplies , supplies are purchased as requested. Soap and paper towels were purchased and placed at each sink 12/02/2020 Staff will inform leadership when supplies are low. Facilities and Leadership will check during house check at least quarterly 12/02/2020 Implemented