Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00248321
|
Renewal
|
07/23/2024
|
Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | There are spider webs on basement window. | Clean and sanitary conditions shall be maintained in the home. | Site Supervisor
Spider webs on basement window were removed 7/24/2024. |
08/29/2024
| Implemented |
6400.80(a) | There were a couple of divots in the concrete walkway to enter the front door of the house that cause a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Site Supervisor
Site Supervisor reported the concrete divots to the Landlord. |
08/29/2024
| Implemented |
6400.105 | The lint trap of the dryer was full of lint. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Site Supervisor removed the lint from the dryer on 7/23/2024.
Site supervisor will inspect premises weekly. They will check the dryer for lint. They will report findings to the Program Director. |
08/29/2024
| Implemented |
6400.151(a) | A physical for staff person #1 was last completed on 2/5/2023. The previous physical was last completed 2/2/2021. | 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. | Human Resources Coordinator
Physical completed on 2/5/2023 |
08/29/2024
| Implemented |
6400.216(a) | There were several program books that contained individuals' records, such as, ISPs and assessments that were unlocked in a basement cabinet. | An individual's records shall be kept locked when unattended.
| Site Supervisor placed the individual¿s records in a locked closet on 7/23/2024. |
08/29/2024
| Implemented |
|
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SIN-00190757
|
Renewal
|
07/27/2021
|
Compliant - Finalized
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|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The bottom left cabinet door in the kitchen was in need of repair. The hinge is either bent or broken not allowing the cabinet door to close correctly and not aligned. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program Director contacted maintenance to repair the cabinet door. On 07/30/2021, Maintenances repaired/aligned the cabinet door. |
07/30/2021
| Implemented |
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SIN-00172044
|
Renewal
|
02/05/2020
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.66 | A light in the kitchen, and one in the dining area were not operable. The entry light into the basement did not stay on consistently stay on. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Blige Electrical Contractor repaired the electrical problem that affected the kitchen and dining area on 2/17/2020.
All Site Supervisors/Program Managers ensured that all light fixtures were operatble by 2/21/2020.
The Self Inspection Tool for 55 Pa. Code Chapter 6400 Regulations will be implemented by the Site Supervisors/Program Managers on a weekly basis as of 6/5/2020. The completed tool will be submitted to the Program Director/Coordinator for their review. All areas of non-compliance will be corrected within a week. The Program Administrator will be informed of all areas of non-compliance and completion plan and date.
Site Supervisors, Program Managers, Program Coordinators and Program Directors will receive training regarding the weekly completion of the Self Inspection Tool by the Program Administrator before or by 6/5/2020. |
06/05/2020
| Implemented |
6400.67(a) | Individual #1's bedroom has mold-like substance on the wall apparently due to hanging wet towels on the hook behind the door. | Floors, walls, ceilings and other surfaces shall be in good repair. | The mold was removed from wall in the bedroom. On 2/7/2020. A towel bar was purchased and will be hung on the bedroom wall by 6/14/2020.
All Site Supervisors/Program Managers ensured that all all were free from mold in all the homes. By 2/14/2020.
The Self Inspection Tool for 55 Pa. Code Chapter 6400 Regulations will be implemented by the Site Supervisors/Program Managers on a weekly basis as of 6/5/2020. The completed tool will be submitted to the Program Director/Coordinator for their review. All areas of non-compliance will be corrected within a week. The Program Administrator will be informed of all areas of non-compliance and completion plan and date.
Site Supervisors, Program Managers, Program Coordinators and Program Directors will receive training regarding the weekly completion of the Self Inspection Tool by the Program Administrator before or by 6/5/2020. |
06/14/2020
| Implemented |
6400.72(b) | A black mold substance around the window frames and sills was located on the 3 bedroom windows. | Screens, windows and doors shall be in good repair. | The black mold was removed from around the window frames in all three bedrooms by the Site Supervisor. On 2/7/2020.
All Site Supervisors/Program Managers ensured that all windows were free from mold in all the homes. By 2/14/2020.
The Self Inspection Tool for 55 Pa. Code Chapter 6400 Regulations will be implemented by the Site Supervisors/Program Managers on a weekly basis as of 6/5/2020. The completed tool will be submitted to the Program Director/Coordinator for their review. All areas of non-compliance will be corrected within a week. The Program Administrator will be informed of all areas of non-compliance and completion plan and date.
Site Supervisors, Program Managers, Program Coordinators and Program Directors will receive training regarding the weekly completion of the Self Inspection Tool by the Program Administrator before or by 6/5/2020. |
06/05/2020
| Implemented |
6400.80(b) | The outside lawn was found covered in trash. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The trash on the outside lawn was picked up and placed in the trash was removed on 2/7/2020 by the Site Supervisor.
All Site Supervisors/Program Managers ensured that all lawns of the homes were free from trash by 2/14/2020.
The Self Inspection Tool for 55 Pa. Code Chapter 6400 Regulations will be implemented by the Site Supervisors/Program Managers on a weekly basis, as of 6/5/2020. The completed tool will be submitted to the Program Director/Coordinator for their review. All areas of non-compliance will be corrected within a week. The Program Administrator will be informed of all areas of non-compliance and completion plan and date.
Site Supervisors, Program Managers, Program Coordinators and Program Directors will receive training regarding the weekly completion of the Self Inspection Tool by the Program Administrator before or by 6/5/2020. |
06/05/2020
| Implemented |
|
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SIN-00145565
|
Renewal
|
11/06/2018
|
Compliant - Finalized
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.168(a) | Staff #1 did not complete an onsite med observation before administering medication. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | On 11/6/2018, Medication Administration Trainer completed two observations of Staff #1 administered medications.
The Medication Administration Program¿s Summary and Certification/Annual Practicum Sheet for newly trained staff will be reviewed by the Human Resources Coordinator upon completion.
Monthly, the Medication Administration Program¿s Summary and Certification/Annual Practicum Sheets for all staff administering medications will be reviewed by the Human Resources Coordinator to ensure observations are completed. |
11/06/2018
| Implemented |
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SIN-00121848
|
Renewal
|
09/22/2017
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.65 | THE UPSTAIRS BATHROOM DID NOT HAVE MECHANICAL VENTILATION AND THE WINDOW COULD NOT BE OPENED BECAUSE IT DOES NOT HAVE A SCREEN. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Program Director contacted the Landlord on 9/26/2017 regarding repair of the window, so it will be operable. The window will be repaired by 10/17/2017 as per the landlord. Attachment #5: 6400.65 - Receipt for repair of bathroom window.
The Program Director will train the Site Supervisors to complete the Monthly Site Checklist that includes living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The Site Supervisors will submit the Monthly Site Checklist to the Program Director by the 10th of each month. As necessary corrections will be indicated. The Monthly Site Checklist will be submitted to the Program Administrator by the 15th of each month. Attachment 2: 6400.77(b)/6400.161(b)/6400.67(a)/6400.65 ¿ Monthly Site Checklist
Training will be completed with Site Supervisors by 11/3/2017
Attachment 3¿ Monthly Site Checklist Training |
11/03/2017
| Implemented |
6400.67(a) | THERE ARE BROKEN KNOBS ON 5 SEPARATE DRAWERS IN INDIVIDUAL #1'S BEDROOM. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program Director purchased Individual #1 a new dresser on 10/19/2017. Attachment 4: 6400.67(a) ¿ Receipt for dresser.
2. The Program Director will train the Site Supervisors to complete the Monthly Site Checklist that includes floors, walls, ceilings and other surfaces shall be in good repair. The Site Supervisors will submit the Monthly Site Checklist to the Program Director by the 10th of each month. As necessary corrections will be indicated. The Monthly Site Checklist will be submitted to the Program Administrator by the 15th of each month. Attachment 2: 6400.77(b)/6400.161(b)/6400.67(a)/6400.65 ¿ Monthly Site Checklist
Training will be completed with Site Supervisors by 11/3/2017
Attachment 3¿ Monthly Site Checklist Training |
11/03/2017
| Implemented |
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SIN-00075888
|
Renewal
|
03/19/2015
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.76(a) | Lint about the size of a baseball was found in the dryer lint trap. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Staff will be trained to clean out the lint compartment upon completion of each dryer cycle. The Site Supervisor will check the dryers at least weekly.Staff of all homes will receive training on the importance of removing lint after each use to increase their knowledge that lint is a potential fire hazard. Staff will also receive training on how to remove the lint after each use. |
05/31/2015
| Implemented |
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SIN-00057798
|
Renewal
|
02/26/2014
|
Compliant - Finalized
|
|
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The self-assessment form was not dated. | (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 of the agency's certificate of compliance, to measure and record compliance with this chapter.
| In the future, when the Program Director completes the self-assessment of each home, within 3 to 6 months prior to the expiration date of the certificate of compliance (April 1), the document will be dated and submitted to the Program Administrator for review. |
01/01/2015
| Implemented |
6400.141(c)(7) | Individual # 1 's last gyn exam was done on 1/25/12. The physician recommended she return in January, 2014. There was no documentation that this appointment occurred. | (7) A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
| The gynecological exam was completed on 03/07/2014 and in the future will be completed as per the physician's recommendations. |
03/07/2014
| Implemented |
6400.213(1)(i) | The client record for individual # 1 did not have a description or identifying marks for this individual. | Each individual's record must include the following information:
(1) 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.
| The individual's Emergency Medical Sheet (Face Sheet) for the individual's record was updated to include the required information. All individuals' records were updated to include the required information. |
03/31/2014
| Implemented |
|
|
SIN-00049233
|
Renewal
|
03/14/2013
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(b)(1) |
Employee #2 was hired on 4/19/11 as a Program Specialist was not informed of the Program Specialist Responsibilities.
| (b) The program specialist shall be responsible for the following:
(1) Coordinating and completing assessments.
| The Program Administrator will inform and re-train the Program Specialist of her responsibilities as per the regulations. The provider will review all new employee records within 30 days of hire to ensure that the required documentation is maintained. |
06/30/2013
| Implemented |
6400.141(c)(7) | Individual #1's last GYN Exam was on 5/12/10. | (7) A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
| Individual #1 had an outdated letter from her PCP in the file regarding frequency. The letter has been updated. |
06/30/2013
| Implemented |
6400.168(d) |
Employee # 2 received initial Medication Administration Training on 6/16/11; an annual practicum was completed on 6/30/12.
| (d) A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually.
| The Program Director has created a tickler system to ensure practicums are completed in a timely manner as per the regulations. Employee # was retrained on 6/14/13. |
06/30/2013
| Implemented |
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