Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00294514 Renewal 08/18/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 11/4/25 is listed as taking 8min6sec which exceeds the 2.5 minute requirement 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. The house manager has been coached to review all fire drill forms for accuracy and compliance prior to signing off on the forms. The staff who conducted the fire drill is no longer employed with the Provider. However, this issue was reiterated in the house meeting that the compliant time can't exceed 2.5 minutes 09/09/2026 Implemented
6400.46(b)Staff Member #1 completed fire safety training on 6/26/25, but the Agency was unable to provide documentation that training was completed in June 2026 to verify annual compliance.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff member #1 did complete the annual training for fire safety training during the 2025-2026 training year as captured in the Relias transcript attached to the POC submission. Unfortunately, Provider had technical issues that did not allow us provide the transcript on the date of the inspection. 09/08/2026 Implemented
6400.52(a)(3)Staff Member #1 completed only 12 countable hours during the 2025-2026 training yearThe following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.Program Specialist actually completed 28 countable hours during the 2025-2026 training year as captured in the Relias transcript attached to the POC submission. This was provided during the site inspection 09/08/2026 Implemented
6400.52(c)(1)Staff Member #1 did not complete training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 2025-2026 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff Member #1 has completed training application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships for the 2026- 2027 training year. See transcript from Relias attached s part of POC submissions 09/08/2026 Implemented
6400.52(c)(2)Staff Member 1 did not complete training on the prevention, detection and reporting of abuse during the 2025-2026 training year.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.Staff Member #1 has completed training on the prevention, detection and reporting of abuse for the 2026- 2027 training year. See transcript from Relias attached s part of POC submissions 09/08/2026 Implemented
6400.52(c)(3)Staff Member #1 did not complete training on individual rights during the 2025-2026 training yearThe annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff Member #1 has completed training on individual rights for the 2026- 2027 training year. See transcript from Relias attached s part of POC submissions 09/08/2026 Implemented
6400.52(c)(4)Staff Member #1 did not complete training on recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff member #1 has completed the training and the certificate is attached as part of out POC submission 09/08/2026 Implemented
6400.52(c)(6)Staff Member #1 did not complete training on the implementation of the individual plans for those supported daily.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.This staff completed ISP trainings for the individual he supported. This is reflected in the Relias transcript that is attached to the CAP submission. Unfortunately, we had challenges extracting the right transcript for this staff on the date of the audit and could not provide it to the inspector. 08/20/2026 Implemented
SIN-00243989 Unannounced Monitoring 04/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There were flies in the window area in individual #1's bedroom. Also, the windowsill had a black substance consistent with dirt.Floors, walls, ceilings and other surfaces shall be in good repair. The window seals were cleaned and inspected for any infestations. There were no signs of an infestation. photos will be sent to show the cleaned window sills. 05/06/2024 Implemented
6400.67(b)The dryer in the home had items like blankets and other household things stored around it in a very tight space. Also, the dryer is located ona shelf that is bowing in the middle appearing to be unsafe. There was a prior leak in the kitchen and the ceiling has been partly repaired but remains unfinished. There was a cabinet next to the refrigerator that was broken with one drawer missing and was coming apart at the edges. There was a table in the living room that had loose legs and was unsteady. Floors, walls, ceilings and other surfaces shall be free of hazards.All debris in the area was removed and the surrounding areas were cleaned. 04/29/2024 Implemented
6400.163(d)A discontinued PRN for individual #1 was found in a medical book for individual #2. Specifically, PRN Docustate, 100mg prescribed to individual #1 was found between the pages of the medical book for individual #2 and the home failed to destroy the prescription in a safe manner according to applicable Federal and State statutes and regulations.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medication has been discontinued on the MAR and properly discarded. 04/22/2024 Implemented
SIN-00219024 Renewal 09/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill has not been held since December 2021A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill was completed on 10/13/2022 at asleep hours to correct the citation. Additionally, a recurring reminder has been set up in the company calendar for all House supervisors and Program Manager to be alerted to perform a fire drill once every six months for each home in the program during asleep hours. 10/13/2022 Implemented
6400.217For individual 3, there was no signed release of information provided.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. A sIgned release of information form was provided for the individual to sign right after the inspection was completed. 09/28/2022 Implemented
6400.34(a)For individual 3, the provided consent forms are past due, with those dated 1/4/21The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.New consent forms were provided for the individual to sign right after the inspection was completed. 09/28/2022 Implemented
6400.34(b)For individual 3, the provided bill of rights is not dated on the signature line, making it impossible to determine if this was provided and reviewed with the individual within the compliant annual time frame.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.New bill of rights form was provided for the individual to sign and also explained to the individual right after the inspection was completed. 09/28/2022 Implemented
6400.165(b)PRN medication (ACETAMINOPHEN 325mg and BENZONATATE 100mg) was in individual 3's medication box and not listed on the MAR. PRN medication (ROBAFEN DM) is listed on individual 3's MAR and not in the medication box at time of inspection.A prescription order shall be kept current.The acetaminophen and Benzonatate were discarded from the box immediately after the inspection. 09/28/2022 Implemented
6400.166(b)For individual 3, the 8pm dosage medication (SENNA 8.6mg and TRAZODONE 50mg) was not logged as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff responsible for administering the medication was retrained on med administration documentation 09/28/2022 Implemented
SIN-00149159 Renewal 01/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency telephone numbers were not on or close to the telephone in the living room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers were located in the home on the staff bulletin Board, but were not posted by the fixed telephone in the living room. The posting was placed by house phone located in the living room by the Program Specialist on 01/25/2019. A new posting was created with more visual effect on 03/11/2019 and replaced the original posting in all locations. See Exhibit 14 The CLA Site Supervisor will monitor to ensure that postings are at each fixed telephone and document on the weekly CLA House Inspection checklist, which will be submitted to the Program Specialist. If the emergency number posting is missing it will be replaced immediately. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. All current staff have been retrained on ( 6400.71) the regulation that emergency numbers must be in place by the fixed house telephone. If the number list is missing it must reported to their supervisor immediately up discovery so it can be replaced. All incoming staff will be trained on the location of the emergency numbers as part of their initial CLA orientation. All current staff have been retrained on the location of the telephone numbers. 01/25/2019 Implemented
6400.77(c)The first aid manual was not in the first at kit. A first aid manual shall be kept with the first aid kit.The Program Specialist placed a first aid manual for the first aid kit in the kit on 01/30/2019. See Exhibit 13 The CLA Site Supervisor will monitor to ensure that the first aid kit has a first aid manual as required by 6400.77(c) and will document the presence of the first aid manual in the kit on the weekly CLA House Inspection Checklist which will be submitted to the Program Specialist. If a first aid manual is missing during the inspection it will be documented and replaced within 24 hours. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. All current staff have been retrained on the regulation that the first aid kit must contain a first aide manual. If a first aid manual is missing, damaged or destroyed the staff must inform their supervisor and the manual will be replaced within 24 hours. All incoming staff, as part of their initial CLA orientation, will be trained that a manual must be present as required content of the first aid kit and their obligation to report any missing, damaged or destroyed first aid manual to their supervisor so the materials will be replaced within 24 hours. Documentation of the training is to be kept as part of the initial staff training record in the employees training file. 01/30/2019 Implemented