Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247540 Initial review 06/28/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Well Water testing not timely. Last tests were 6/20/24 and 1/15/24, exceeding the three-month requirement between tests.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Although there was a period of non compliance for water testing, at the time of the inspection the well at the home had been tested recently on 6/20/24 (this record was reviewed during the inspection and is not attached). Repeat testing is not due until August 2024. Review of all water testing records was not necessary because we only have one other location with a well, which was also inspected on 6/28/24 and found to be non compliant so POC will be submitted for violation attached to that location. 07/18/2024 Implemented
6400.112(d)Fire drill exceeded two and a half minutes. The drill conducted on 1/13/2024 lasted three minutes. 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. On 7/15/24 VP reviewed all of the fire drill records for the individual living at Berks rd since 2022 (This is a 1 person cite and he has been the only person living there) and all other fire drills completed have been under the allotted time of 2 minutes and 30 seconds. The fire drill completed on 2/16/24 was completed in 1 minute and 10 seconds. VP reviewed other Therap documentation related to this individual around the time of the drill to assess if the individual was having any issues out of the ordinary, but nothing was found. VP met with HAP management team, including clinical director who is the individual¿s behavior specialist on 7/17/24. Management team confirms that this individual has never had an issue evacuating for fire drills. Program Specialist met with SC and family at individual¿s ISP meeting on 7/17/24 and all agreed that the individual is able to evacuate during the allotted time frame. There is no way to assess 6 months after the fact what happened to cause the January 2024 drill to be over the time limit, but the most likely cause is that it was a documentation error and the time for the evacuation was not recorded correctly. VP reviewed all fire drill records for each HAP, Inc home. No other fire drill in 2024 was over 2 minutes and 30 seconds. 07/25/2024 Implemented
SIN-00227012 Renewal 06/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)Fire extinguishers throughout the house, on each floor, did not have the date of their inspection listed on their tags. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On 7/11/23, Director of quality development spoke with John S posen inc and scheduled for them to meet at Berks rd on 7/21/23 to fix the extinguisher tags. On 7/21/23, maintenance manager met with inspector from John S posen inc at Berks rd in order to get the tags fixed that they had forgotten to punch in January. All fire extinguishers now have the date of inspection on them. 07/21/2023 Implemented
6400.186Individual 1's ISP indicates poisons should be kept locked as a precaution. Poisons were found unlocked throughout the house: a laundry detergent pod in an unlocked drawer in the bathroom that contains the washer and dryer; antibacterial hand soap on a sink in that same bathroom as well as a sink in the second floor bathroom; and cans of paint in the individual's art studio/spare office space.The home shall implement the individual plan, including revisions.The poisons that were left out were locked up by the CEO at the time of the inspection on 6/30/23. 06/30/2023 Implemented
SIN-00207672 Renewal 06/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The desk in the vacant upper level bedroom used for art was damaged. The two left drawers were broken.Floors, walls, ceilings and other surfaces shall be in good repair. The desk has been replaced. All homes have been inspected by maintenance personnel to insure that equipment and furnishings are in good repair. 07/10/2022 Implemented
6400.82(e)The main level shower did not have a non slip mat or surface. Bathtubs and showers shall have a nonslip surface or mat. The mat that was previously in the shower was discarded and not replaced. A new mat was purchased and is now in place in the shower. All other homes were inspected by maintenance personnel and found to have non-skid surfaces in the showers. 07/15/2022 Implemented
6400.52(c)(2)Documentation was not provided notating the completion of training of abuse prevention detection and reporting for the 2021 training year for staff 1.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.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/19/2022 Implemented
6400.52(c)(3)Documentation was not provided notating the completion of training of individual rights for the 2021 training year for staff 1.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/19/2022 Implemented
6400.52(c)(4)Documentation was not provided notating the completion of training of recognizing and reporting incidents for the 2021 training year for staff 1.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/19/2022 Implemented
6400.52(c)(5)Documentation was not provided notating the completion of training of behavioral supports for the 2021 training year for staff 1.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/19/2022 Implemented
6400.169(d)There is no record of medication administration training for staff 1 prior to June 27, 2022. Staff administered medication the month of June and prior months. The medication trainings provided show that staff 1 was currently trained on 6/27/22.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/01/2022 Implemented
SIN-00189452 Renewal 06/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)It could not be determined that records of corrections were kept for all violations captured on the agency's July and August 2020 self-assessments for at least a year, as those records were not available at time of inspection.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Self assessments were conducted in June 2021 and included records of corrections. Attachment C 06/30/2021 Implemented
6400.151(a)It cannot be determined that staff member staff #2 has had a physical within the past two years. The most recent physical and TB test observed in agency documents was dated February 2019. 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 #2 has not completed a physical despite numerous notifications. Staff #2 has not provided any explanation as to shy this has not been completed. Staff #2¿s employment has been terminated. ATTACHMENT D All employment records have been reviewed to ensure that all staff have completed a physical within the past two years. 07/21/2021 Implemented
6400.46(d)First aid/CPR training was past due for staff #1; the past due date includes the additional 120 days granted from the American Red Cross Association in response to Covid-19.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #1 has completed CPR/First Aid Training. Attachment E All staff records have been reviewed to ensure current certification for CPR and First Aid training. 07/15/2021 Implemented