Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00277602 Renewal 11/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment documentation, completed between 7/15-30/25, was incomplete. The self-assessment did not address regulations 6400.22g through and including 6400.25d and regulations 6400.151a through and including 6400.152c. These sections of the self-assessment were left blank.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. In accordance with 55 PA Code 6400.15(a) 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 of the agency's certificate of compliance, to measure and record compliance with this chapter. 12/29/2025 Implemented
6400.21(a)Direct Services Worker (DSW) #1, date of hire 3/28/2025, had an application for a Pennsylvania criminal history check submitted on 8/1/25. This exceeds 5 working days after the person's date of hire. Additionally, DSW #1 has a criminal history and the agency failed to review DSW #1's criminal record and document the case-by-case decision to hire the person.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. In accordance with 55 PA Code Chapter 6400.21 (a) an application for a Pennsylvania criminal history check shall be submitted to the State Police for prospective employees of the agency 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. 12/29/2025 Implemented
6400.141(c)(3)Individual #1 had a physical examination, completed 3/27/25; however, the physical examination did not include record of a tetanus immunization.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. In accordance with 55 PA Code Chapter 6400.141 (c)(3) the physical examination shall include immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. 12/29/2025 Implemented
6400.181(d)Individual #1 had an assessment that included assessment codes that were dated 6/13/25; however, the Program Specialist did not sign and date the assessment. Therefore, the assessment was incomplete.The program specialist shall sign and date the assessment. In accordance with 55 PS Code Chapter 6400.181 (d) the program specialist shall sign and date the assessment. 12/19/2025 Implemented
6400.18(i)Enterprise Incident Management incident #9681832 had a due date for the incident final section of 9/24/25. The incident final section was submitted by the agency on 10/29/25. No extension was filed for this incident.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.In accordance with 55 PA Code 6400 (18) (i) the provider shall finalize any incident report through the Department's information management system within 30 days of discovery of the incident by a staff person unless the provider notifies the Department in writing that an extension is necessary and the reason for the extension. 01/16/2026 Implemented
SIN-00258117 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home did not complete a self-assessment of the home. The documents provided during the inspection were not dated, did not contain the address of the home, and most of the regulations were left blank.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. In accordance with 55 PA Code Chapter 6400.15 (a) 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 (10.7.25) of the agency's certificate of compliance to measure and record compliance with this chapter. 01/13/2025 Implemented
6400.112(c)Upon review of fire drills on 11/6/2024, no exit routes were documented on any fire drills conducted since the agency's last renewal inspection, conducted 11/14-15/2023.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. In accordance with 55 PA. Code 6400.112(c) - 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 detectors was operative. 11/07/2024 Implemented
SIN-00234834 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record provided from 12/5/22 to 10/7/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered.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. On 11/21/2023 the agency representative (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drills and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drill performed. 11/21/2023 CEO trained Program Specialist and Supervisors on updated Fire Evacuation Record. 12/14/2023 Implemented
6400.216(a)At 11:22 AM on 11/15/23, Individual #1's records were found unsecured in a non-locking cabinet located in the apartment's living room area. An individual's records shall be kept locked when unattended. On 11/17/2023 the agency purchased a file cabinet with a locking system to store binders appropriately. On 11/20/2023 the binders were placed in the file cabinet by site supervisor to be stored appropriately. The site supervisor will monitor if the binders are being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. 11/17/2023 Implemented
6400.32(h)On 11/15/23, Ring cameras that record audio and video were observed outside the apartment unit's front door, on the side balcony, and in the living room common area. A consent form was presented by the agency and signed by the individuals. The CEO #1 stated that the live feed captured on the cameras is directed to an iPad that is accessible only to CEO #1 and Administrative Assistant #2. CEO #1 further explained that the live feed disappears from the iPad after seven days but that there is an option to save the recordings for an unlimited period of time.An individual has the right to privacy of person and possessions.On 12/7/2023 the audio was removed from the front door camera by disabling the audio in the system, there is no side balcony attached to this apartment, the audio was removed by disabling the audio in the system from the living room common area location. The audio will remain disabled at all times during recording. The CEO will monitor the function of the device to ensure quarterly to ensure compliance is being met. On 12/7/2023 the CEO will train the administrative assistance on the regulation surround the use of cameras in a residential settingOn 12/6/2023 the maintenance man removed all chain locks from the door. Leasing office was informed that those type of locks cannot be used in the future. On 12/07/2023 the Program Specialist check all locations to ensure locks were removed. The site supervisor will monitor locks on lead checklist monthly to ensure compliance is being met, Program Specialist will monitor lead checklist monthly and site location quarterly to ensure compliance is being met for 1 year. The CEO trained the Program Specialist on appropriate lock systems and when and how they should be used. 12/07/2023 Implemented
6400.32(r)(1)On 11/15/23, Individual #1's bedroom door was observed with a key lock. However, Individual #1 did not have access to their own key to permit them to unlock and lock their bedroom without having to consult with staff.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.On 12/4/2023 the individual was given a key to her bedroom door. It was placed on her key ring along with her other keys by agency representative (Program Specialist) . The site supervisor will check the individual's key ring monthly to ensure that it's there and marked the status of the key on the lead checklist. The Program Specialist will view monthly check list every month and do a site quarterly check to prevent the violation from occurring again. On 12/4/2023 the CEO trained the Program Specialist and site supervisors on the individual's right to have a lock and key to their bedroom door. 12/04/2023 Implemented
SIN-00215241 Renewal 11/22/2022 Compliant - Finalized