Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00208220 Renewal 07/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A container of Clorox spray was unlocked and accessible at time of inspectionPoisonous materials shall be kept locked or made inaccessible to individuals. The Clorox Spray was removed immediately on 7/13/22. Staff were re trained on 6400.62(a) and the shift responsibility checklist, which includes ensuring that all cleaning products are removed. 07/13/2022 Implemented
6400.68(b)Water Temp was 127.0°F at the time of inspection Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature was adjusted to under 120 degrees 7/15/22. All staff were trained on 6400.68 (b) and a water check form was created in order to track water temperature measurements. 07/15/2022 Implemented
6400.104The fire department letter was not updated when the capacity of the home changed in August 2021, a recent letter has since been mailed on 6/29/2022 to the local fire department .The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The Program specialist will update the fire department when any changes are made and the admission check list has been revised to include notification to fire department when changes are made in the home and Program specialist and Team Leads have been trained on 6400.104 on 8/2/22 08/02/2022 Implemented
6400.112(e)The sleep drills were not completed every 6 months. There were no sleep drills conducted in the 6 month period between 1/1/2022 through 6/30/2022. A sleep drill was recently conducted in July 2022 and previously completed in December 2021.A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill was completed in July 2022 as noted. The next drill will be completed January 2023 to get on a 6 month schedule that ensures compliance. Additionally, Team Leads and Lead workers were trained on 6400.112(e) 07/15/2022 Implemented
SIN-00200404 Renewal 07/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Fire Letter dated 7/6/21 stated that there were 2 individuals living in the home however there were 3 individuals in the home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. All Fire Letters have been updated for the cited home effective March 2022, as well as for all other homes. 03/16/2022 Implemented
6400.110(a)The smoke alarm located in the basement was not operational at time of inspection. ** Staff replaced the battery and it was operational while I was out there ** A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Smoke Alarm replaced in July 2021. 07/16/2021 Implemented
6400.111(f)The fire extinguishers in the bathroom/laundry room as well as the fire extinguisher in the basement were both last inspected in January of 2020. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire Extinguishers were checked by Johnson Control in August 2021. 08/02/2021 Implemented
SIN-00143856 Renewal 10/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror in individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was placed in Individual #2's bedroom. All other homes were checked to ensure that there was a mirror in all bedrooms. The house supervisor/manager will be trained on the 6400 regulations with emphasis on the physical site section. 01/11/2019 Implemented
6400.213(1)(i)Individual #1's record did not contain eye color or identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual #1's record did not contain eye color or identifying marks. Individual #1's face sheet was corrected to include the missing information. All other face sheets were reviewed to ensure that all information required by 55 PA Code Chapter 6400.213 (1)(i) is present. The Vital Statistic form will be renamed to Client Data Summary and will include all required information. The Program specialist will be responsible for updating all Client Data Summary sheets annually at the time of the assessment. The Program Specialist and Residential Manager will be trained on 55 PA Code Chapter 6400.213(1)(i). 01/11/2019 Implemented
SIN-00116108 Renewal 04/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical exam dated 6/22/16 did not include 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. Information pertinent to diagnosis in case of emergency is missing from physical is missing from the physical. The Health Care Coordinator (HCC) will consult with the PCP to get the missing information documented and attach it to the annual physical in the client file. In addition all physical exams for all individuals will be reviewed to ensure that the section asking for information pertinent to diagnosis in case of emergency has been completed. If any are missing the HCC will ensure that the PCP is consulted to provide the missing information and that information will be documented and attached to the annual physical in the client file. The program supervisors and HCC will be trained on completing the physical examination and all 6400 regulations associated with the annual physical.. Each year for all individuals, the program supervisor will ensure that all sections on the physical examination are completed by the physician. The HCC will do a final review when processing all completed physicals to ensure that all sections are filled in. 12/19/2018 Implemented
SIN-00084869 Renewal 12/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 9/01/15 was not completed 3-6 months prior to the expiration of the license on 11/11/15.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. management staff trained on the regulated time frame for self-assessments to be completed. Training sign in sheet attached. 03/11/2016 Implemented
6400.64(a)The self-assessment dated 9/01/15 was not completed 3-6 months prior to the expiration of the license on 11/11/15.Clean and sanitary conditions shall be maintained in the home. management staff trained on the regulated time frame for self-assessments to be completed. Training sign in sheet attached. 10/27/2016 Implemented
SIN-00093328 Renewal 12/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 9/01/15 was not completed 3-6 months prior to the expiration of the license on 11/11/15.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. All staff in the position of conducting the annual self-inspections have been educated on the regulatory time frame for completing self-inspections in relation to the licensing expiration date. 09/14/2016 Implemented
6400.64(a)Individual #1¿s bedroom has brown Stains on the carpet in front of her bed. The size of the area is about 1ft by 1ft.Clean and sanitary conditions shall be maintained in the home. Carpet will be professionally shampooed and going forward supervisory staff will conduct monthly physical site reviews of all regulated areas of clean and sanitary conditions 09/14/2016 Implemented
SIN-00066730 Renewal 09/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was not completed for this 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. a self assessment was completed and sent to wszott@pa.gov 10/31/2014 Implemented
6400.62(a)Conatiners of Lysol spray, bleach and Lysol bathroom cleaner were found unlocked in the bathroom near the kitchen. These chemicals included labels that documented to call Poison Control if accidentially swallowed. The individual of this home has not been assessed to safely handle poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. all potentially poisonous materials were placed in locked cabinet. The lock was replaced. 09/29/2014 Implemented
6400.77(b)The first aid kit is missing tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezers were replaced in the first aid kit 09/29/2014 Implemented
6400.81(k)(6)Individual # 1's bedroom is missing a mirror.In bedrooms, each individual shall have the following: A mirror. A mirror was placed in the bedroom of Individual #1 09/29/2014 Implemented
6400.161(b)Ibuprofen and allergy relief medications were found in a cabinet unlocked above the toilet in the bathroom, located near the kitchen.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. ibuprofen and allergy relief medication was removed from cabinet. Staff was reminded of the regulation and all potentially non-toxic medication will be kept in a locked container. 09/29/2014 Implemented
SIN-00053249 Renewal 09/23/2013 Compliant - Finalized
SIN-00050419 Initial review 05/13/2013 Compliant - Finalized