Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244201 Renewal 05/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window in the upstairs vacant room was broken and unable to hold itself up. Screens, windows and doors shall be in good repair. A maintenance ticket was submitted on 5/9/24 by Associate Director. Maintenance technician repaired the window on 5/13/24 and the window now stays open. See attachment labeled 72b Vulcan Window Repair. 05/13/2024 Implemented
SIN-00166422 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)Outside Individual #2's bedroom door on the side of the house, the central air system has a major leak causing a puddle of water. The Hose is not connected. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The pipe has been repaired to drain away from the home 9/25/19. (Attachment #17) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/21/2020 Implemented
6400.141(c)(15)On individual #1's Annual Physical Exam completed on 4/30/19, the Special diet instructions was left blank.The physical examination shall include:Special instructions for the individual's diet. Individual #1 does not have a Special Diet. The Physical Form was amended to reflect "No" under this section. (Attachment #18) Going forward, any Annual Physical with No Special Diet shall be marked "No", "None" or "regular diet". 12/12/2019 Implemented
6400.168(d)Staff person #1's Annual medication practicum was last completed on 6/27/18, which is more than a year.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Staff person #1's documentation of completing medication administration practicum was dated incorrectly by the trainer's signature. Date has been corrected by the trainer based on supporting documentation on 9/12/19 and she is current on her training requirements. (Attachment #19) Going forward, the new Director of Training and training department will track and ensure all required paperwork for all staff. 03/01/2020 Implemented
6400.181(e)(1)Individual #1's Annual Assessment completed on 9/17/19 it was unclear what the individuals strengths and preferences were, what was documented was vague. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Assessment template redone on 10/1/19 to update and amend to include clear strengths needs and preferences. (Attachment #3) Individual #1's assessment has been redone on the new template and sent to his team for approval and sign offs. . (Attachment #20) Going forward all assessments will be completed on the new template by the Program Specialists. 12/13/2019 Implemented
SIN-00140932 Renewal 08/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(e)Individual #6 had a scheduled dental appointment on 7/31/18 and it was not kept.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The Residential Manager is required to complete all required medical appointments within timeframes identified by regulations and the individual's physician. Copies of the medical appointment summaries are faxed to the office and entered into the medical records data base by the Medical Records Coordinator. The Program Specialist is required to review medical appointment summaries and ensure the manager schedules any follow up appointments needed. The Medical Records Coordinator meets with each Program Specialist on a monthly basis to review what appointments are coming due for the upcoming month. The Medical Records Coordinator documents scheduled appointments coming due, identifies any that are overdue and notifies the Associate Director. Associate Directors are responsible for monitoring completion of appointments in a timely manner. Going forward, the Associate Director will also review upcoming appointments that are due and ensure that the appointment is completed on time by the Program Specialist. 09/04/2018 Implemented
6400.186(a)There were 3 three month ISP reviews for individual #6 that were not completed on time. The review from 9/4/17 through 12/3/17 was completed on 2/6/18. The review from 12/4/17 through 3/3/18 was completed on 7/24/18. The review from 3/4/18 through 6/3/18 was completed on 7/19/18.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. The Program Specialist is required to complete all 3 month ISP reviews for each of the individuals on their caseload. They then turn it in to their Associate Director for review and approval. Due dates for each individual's 3 month ISP review is tracked by our Medical Records Coordinator. The Medical Records Coordinator meets with each Program Specialist on a monthly basis to review what paperwork is due for the upcoming month. The Medical Records Coordinator documents any paperwork due and areas of noncompliance and notifies the Associate Director. Associate Directors are responsible for monitoring completion of paperwork in a timely manner. Going forward, the Associate Director will also review upcoming reviews that are due and ensure that the review is completed on time by the Program Specialist. 08/30/2018 Implemented
6400.213(1)(i)Individual #6 did not have a current photo in his record.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. A photo for individual #6 was placed in Their chart during the licensing visit on 8/15/2018. The Program Specialists are responsible for maintaining those records. If any photos are not in an individual's chart or if the photo is over 5 years old, the Program Coordinator will place an updated photo in the chart. The Associate Directors are responsible for completing chart reviews for each individual on their caseload to ensure all requirements are met. Any areas of noncompliance will be noted during those audits and corrections will be made. 08/16/2018 Implemented
SIN-00123282 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
Article X.1007Delta is required to maintain criminal history checks in accordance with the Older Adult Protective Services Act (OAPSA). Staff # 1's date of hire was 02/13/17 and there was no documentation of PA. residency or completion of FBI clearance.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.All new hires sign an affidavit to validate PA residency. Associate Director of Human Resources revised the new hire tracking form to document if affidavit was signed (Attachment #1). The recruiter and the human resources clerk are both responsible for double checking residency, ensuring the affidavit is signed, and that an FBI check is completed accordingly. 08/01/2017 Implemented
SIN-00091501 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff # 24's initial medication administration training dated 05/16/2015 was invalid as the paperwork was not properly completed by the trainer. 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. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1 . All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
6400.168(d)Staff # 23's annual medication administration training dated 10/01/2015 was incomplete as the fourth MAR review was completed on 12/12/2015. Staff # 23's practicum observer training dated 07/08/2015 is invalid as there were no observations completed. Staff # 41's practicum observer training dated 03/07/2016 is invalid as there were incomplete observations A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
Article X.1007Delta is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #24's date of hire was 05/04/2015 and there was no documentation of PA residency for two years or the completion of a FBI check.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Associate Director of Human Resources revised the format to perform FBI checks on candidates who have not resided in Pennsylvania for at least 24 months prior to hire. An additional line was added to the checklist to ensure anyone with less than 24 months of PA residency will have an FBI check completed upon hire. The recruiter and the Human Resources clerk are both responsible for double checking residency and that an FBI check is completed accordingly. Attachment # 3 05/12/2016 Implemented
SIN-00075955 Renewal 02/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Individual #1 was not administered prescribed medications, Fluticasone Spray 50mcg daily, and Icy-Hot patch every 12 hours which were listed on the medication log, but were not administered to the Individual from 2/1/15 through 2/25/15. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. HCSIS report #7192533 was filed on 2/27/2015. Meds were administered but not noted on the MAR. Medication remediation training was completed for all staff on 3/9/15. The Associate Director will monitor compliance with medication administration on a monthly basis by reviewing the MAR's. Direct care staff that administer medications will check the MAR's daily to ensure that all of the medications that are administered will be documented on the MAR's immediately following administration of each dose of medications or treatments. 03/09/2015 Implemented
6400.186(a)Individual #1's three month reviews were dated incorrectly. The review ending 9/30/14 was dated 9/5/14, the review ending 6/30/14 was dated 6/2/14, and the review ending 3/30/14 was dated 3/2/14.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. Staff training was completed on 3/4/15 on three month reviews including how to write reports, contents of reports, purpose of reports, and timeliness of reports. Staff were instructed to write the review period on the report. Associate Directors will monitor compliance with three month reviews. 03/04/2015 Implemented
Article X.1007The provider is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 - 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #6's, hired on 12/1/14, criminal history check was completed on 12/5/14.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The person responsible in the past for insuring the timely processing of criminal record checks has been separated from Delta. A replacement has been identified and will be fully trained in the requirements of criminal record checking on their first day on the job. Remaining HR staff have been trained/re-trained in the requirements of processing criminal record checks on March 2, 2015 Fern Granoff, Associate Director of HR, will be responsible to check the processing of criminal record checks prior to the new employee starting. The Associate Director will audit of the new employees hired in the past 12 months to ensure that all of the Criminal History checks have been completed in accordance with the OAPSA and will develop a new hire checklist to ensure that the Criminal History checks are completed prior to hire. 03/02/2015 Implemented
SIN-00063888 Unannounced Monitoring 05/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 did not have an up to date financial record. Funds totaling 25.13 were missing. Individual #2 did not have an up to date financial record. Funds totaling $46.61 were missing. (2) Disbursements made to or for the individual. Individual #1 was reimbursed $25.13 on 4/14/14. Ledger was reviewed by management. $20 deposit not listed on ledger. Also missing receipt for $5.13. Family is rep-payee, they were reimbursed on 4/14/14. Individual #2 was reimbursed $46.61 on 5/7/14. Documentation will be forwarded via email. 1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached.2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached.3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. 06/06/2014 Implemented
6400.22(e)(3)Individual #1 was missing receipts for $25.13. Individual #2 was missing receipts for $46.61. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Increase training and management review of monthly ledgers. Reviewed financial procedures. Error made by staff with performance issues and job abandonment. Management will review receipts and ledgers on a weekly basis. 1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached. 2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached. 3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. 06/06/2014 Implemented
SIN-00047506 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)On 6/25/12, 7/12/12 and 10/24/12, 11/28/12, 12/14/12, 1/17/13, 2/27/13, 3/8/13 the front door was use to exit during monthly fire drills.(f) Alternate exit routes shall be used during fire drills. We have revised fire drills forms to note alternate exits used. Staff training was held on 4/5/2013. PD will monitor monthly use of alternate exits. 04/22/2013 Implemented