Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00267270 Renewal 05/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Program Specialist #1, date of hire 11/7/2024, had an application for a Pennsylvania Criminal History Record Check completed on 10/23/2023.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. Program Specialist # 1, PA Criminal History Record Check was received in January 2025. This cannot be corrected immediately. A plan has been implemented to ensure that during the pre-hire process, the Human Resource Manager will examine all the documents completed by the applicant for completeness and submit all applications. Applications to be submitted include but are not limited to FBI Clearance, PA Criminal History Record Check, PA Child Abuse, MVR, education verification and employment verification, as applicable, on the date of hire. 06/24/2025 Implemented
6400.165(g)Individual #1's psychiatric medication review, completed 10/22/2024, did not include Individual #1's medications. Individual #1's psychiatric medication review, completed 12/11/2024, did not include the dosages and reason for prescribing the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.An immediate corrective action is not able to be completed to correct Individual #1¿s Psychiatric Medication Review that took place on 10/22/2024 due to this being a past appointment. An immediate corrective action is not able to be completed to correct Individual #1¿s Medication Review completed on 12/11/2024, due to the appointments being past medication monitoring appointments. On June 16, 2025, Community Care Connections implemented a new Medication Monitoring form to be completed at all medication monitoring appointments. The Medication Monitoring form requests documentation for: reasons for medications, dosages of medications, need to continue medications, and a list of current medications. 07/01/2025 Implemented
SIN-00246513 Renewal 06/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 6/06/2024 at 11:45 AM, Individual #1 had dual side bed rails that restricts the movement or function of their body. On 6/06/2024 at 11:50 AM, Individual #2 had dual side bed rails that restricts the movement or function of their body.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.* Provider confirmed that Individual #1 and Individual #2 are able to move freely and get in and out of bed independently with the bedrail. * IDT meeting was held for individual #1 and it was determined that Individual #1 is incapable of removing. Cathy is able to communicate to staff when she wants her bedrail up and down. She utilizes her bedrail to prevent falls due to a history of this in the past. A doctor's script was obtained by the provider. * IDT meetings were held and it was determined that Individual #2 is capable of removing the rails independently. Individual #2 has a doctor's script for bedrail for the purpose of transferring in and out of bed from their wheelchair. * Provider updated the assessment for Individual #1 and Individual # 2. * Provider requested that the Supports coordinator for Individual #1 and Individual #2 update the ISP. 07/02/2024 Implemented
SIN-00155272 Renewal 05/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(e)Direct Service Worker #1, administered Benztropine, 1 mg tablet, at 9:00PM on 3-23-19, and Oxybutynin, 5 mg. tablet at 9:00 PM, on 3-17-19, to Individual 1#. Documentation for Direct Service Worker #1's medication administration training was not available. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.Staff #1 had only the ¿student certification form¿ when she came to work for us from another agency. We contacted her previous employer, but they reported they were unable to provide us with additional documents due to their policy. We are unable to correct this violation. Before working again, staff #1 was trained and tested by a certified trainer from Community Care Connections on 5/16/19. The training documentation and the trainers certificate will be forwarded. To prevent this from occurring again, Community Care Connections will ensure that any potential new-hire will have the student certification form, the annual practicum summary sheet, summary certification sheet of initial training and the trainers certificate. If we are unable to obtain all of these documents, we will do a complete new training. Supervisors and medication trainers were trained on this regulation on 5/16/19. Documentation will be forwarded. [Immediately and at least quarterly for 1 year, a designated management staff person shall audit all staff person responsible for medication administration to ensure documentation of the medication administration training for trainers and staff persons are available for review upon request by the Department. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 5/28/19)] 05/16/2019 Implemented
SIN-00095540 Renewal 05/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door exit was used in the monthly fire drills held from April 2015 through March 2016Alternate exit routes shall be used during fire drills. We are unable to go back and correct the fire drills from the previous year. We did add a reminder to the fire drill record reminding staff to alternate exits used. In an effort to prevent this error from occurring again, we trained all direct-care and supervisory staff on regulation 6400.112(b). Special emphasis was placed on alternating exit routes. Supervisory and Administrative staff were also trained on 112(b)(1) and the importance of monitoring and signing all drills for compliance. A copy of all training verification and the adapted ¿Fire Drill Record¿ will be forwarded. A copy of the most recent drill using an alternate exit will also be forwarded. [Documentation of supervisory and/or administrative staff review of fire drills shall be kept. (AS 6/24/15)] 06/10/2016 Implemented
SIN-00063407 Renewal 05/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1's gynecological exam was completed on 7-19-2013, and the prior exam was completed on 6-14-2011. Individual #1's physician recommended that the gynecological exam be completed every two years. The physical examination shall include: 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. We are unable to correct this violation for Individual #1. To prevent this from happening in the future, Supervisor will schedule follow-up and annual appointments when they are leaving the doctors office. For doctors who do not schedule that far in advance, we will schedule after one year or six months, depending on their policy. If a doctors office is unable to schedule an appointment within regulations, written documentation stating why, will be obtained from that doctor. The Program Specialist will continue to monitor compliance. 05/19/2014 Implemented
6400.186(a)Individual #1's 3-Month Review was completed on 3-28-2014, and the prior review was completed on 12-05-2013.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. PS is unable to correct Individual #1's review. To prevent this from occurring in the future, the PS has created a spreadsheet to record meeting dates for the year. The PS will take this form to quarterly meetings and reference it when scheduling the next meeting with other team members. 05/19/2014 Implemented
SIN-00228371 Renewal 07/10/2023 Compliant - Finalized
SIN-00191849 Renewal 08/24/2021 Compliant - Finalized
SIN-00175993 Renewal 09/09/2020 Compliant - Finalized
SIN-00115946 Renewal 06/13/2017 Compliant - Finalized
SIN-00077766 Renewal 05/05/2015 Compliant - Finalized