Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288739 Unannounced Monitoring 05/04/2026 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(a)In April 2026, Delta Community Supports Inc. identified through an internal self-audit that numerous staff members had not successfully completed the Department's initial medication administration training course. Specifically, staff failed to complete all required components of the training including the completion and proper documentation of the mandatory medication observations necessary to demonstrate competency. As a result, untrained staff members administered medications without successful course completion in accordance with the Department's medication administration requirements.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Following the discovery of missing documentation related to residential staff medication administration certifications, the Training Director immediately began scheduling classes to recertify all residential staff with any missing or incomplete documentation. The classes have been and will continue to be scheduled for the following dates: 5/9/2026, 5/11/2026, 5/12/2026, 5/15/2026, 5/28/2026, 5/29/2026, 5/30/26. Classes will continue weekly between Bucks and Delaware County. In addition, a new tracking process was implemented to address the current corrective action plan and ensure ongoing compliance moving forward. Attachment #1 outlines the following within each tab: all CL staff (Community Living staff), CC staff (Community Center staff), retraining plans, schedules, PO-certified staff (Practicum Observers), Medication Trainers, and certification information. This spreadsheet will be maintained on an ongoing basis by the Training Administrative Assistant following all formalized training conducted by the Training Director. All identified retraining will occur on or before 6/12/2026. No new hires or Community Center staff added to the spreadsheet will be authorized to work in a residential home until they have completed and passed the classroom medication administration class and two mock observations. At this point they will be designated as "yellow" within Attachment #1. "Green" status will only be assigned once initial training and all four required observations have been successfully completed. Observations 3 and 4 will be scheduled for day one in the group home and further training will not continue until these have been completed. Once observations 3 and 4 are complete staff will be converted to "green" on the tracking spreadsheet. All supporting training documentation, including the two required observations, will be verified and filed by the Training Administrative Assistant. Moving forward if an employee is unable to complete the medication administration training and two mock observations with a passing mark during new hire orientation, this will result in immediate separation of employment. Additionally, all fill-in coverage for residential homes from other programs must be approved by both the PA State Director and the Senior Director of Community Supports. This process will ensure that no employee who is not fully certified in medication administration works in a residential setting. Finally, all residential staff listed within the retraining tab must complete the full training requirements by 6/12/2026 or they will no longer be authorized to work in a residential home. Until training is completed, the identified backup plans listed in attachment #1 will remain in place. 06/12/2026 Not Implemented
6400.169(a)Staff #1's annual practicum should have been completed by 5/5/25 but only had one MAR review completed on 1/24/25 and one observation on 3/20/25, the other MAR review was completed on 6/26/25 and the observation was completed on 7/27/25. Staff #2's last annual recertification was on 6/25/2017. Staff #3's annual practicum should have been completed by 5/17/25 but only had one MAR review completed on 1/13/25 and one observation on 4/1/25, the other MAR review was completed on 9/25/25 and the observation was completed on 9/25/25.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Staff #1 Completing annual review by 6/5/26 - currently a community center staff Staff #2 Termed on 2/23/26 Staff #3 Initial Training was re-done 3/7/2022. Med Obs & MAR Reviews for 2025 (4/1/25 and 9/25/25), and 3/1/2026. 06/12/2026 Not Implemented
SIN-00224305 Renewal 05/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)FBI background check for staff member#1 was completed 7/29/22 date of hire was 6/9/22, this was not completed within required timeframe of within 5 working days after the person's date of hire.If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. "Under the direction of the new CHRO, a process change was implemented on April 19, 2023. The change requires all incoming employees who require an FBI criminal history record check, to complete the fingerprinting process and to provide a copy of their receipt prior to onboarding. On May 23, 2023 Human Resources staff were retrained on 6400.21(a)(b) and 6400.151(a)(c). supporting documentation labeled HR Clearances for Licensing Training" 05/23/2023 Implemented
6400.82(e)No slip mat was in the shower located in the bathroom #1 (this was corrected at time of inspection). Bathtubs and showers shall have a nonslip surface or mat. A bathroom mat was placed in the shower in Bathroom #1 by the Associate Director on 5/10/23. Corresponding photo 6400.82e-Andover Rd 06/30/2023 Implemented
SIN-00166423 Renewal 09/10/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)The overnight staff logs were not complete, and you could not determine if the staff was checking on the individuals in the home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. A Sleep Check training was developed by the agency nurse on 9/11/19 and all staff were trained. (Attachments #5 & 21) 09/25/2019 Not Implemented
6400.46(f)Staff person #1's Last fire safety training was completed on 8/14/18.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff Person #1 was re--trained on fire safety on 10/22/19. (Attachment # 22) Going forward, the new Director of Training and training department will track and ensure all required fire safety training paperwork for all staff. 03/01/2020 Implemented
6400.81(k)(6)There were No mirrors found in individual #1 or individual #2 bedrooms.In bedrooms, each individual shall have the following: A mirror. Mirrors purchased and hung in the bedrooms on 9/26/19. (Attachment # 23) 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. 02/01/2020 Implemented
6400.144Individual #1's medication Olopatadine sol 0.2% eye drop was not in the medication box. (later replaced during inspection) Individual #1's medication Nystatin TOP POW 100,000 was not in the medication box. (later replaced during inspection)In bedrooms, each individual shall have the following: A mirror.Medications missing during inspection were found on site during the licensing visit and placed in the medication box. Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. 01/01/2020 Implemented
6400.161(e)Individual #1's medication Ducodyl tab 5mg was not in the medication box, but the medication was on the medication log. The house manager stated the medication was discontinued, but no documentation was provided to verify.Discontinued prescription medications shall be disposed of in a safe manner.Medication was removed same day as site visit. Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. 01/01/2020 Implemented
6400.166(a)(7)Individual #1's medication Cepacol cgh loz 5-7.5mg was not listed on the medication log, but it was in the medication box.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The MAR was amended to add the Cepacol medication. (Attachment #24 ) Going forward, re-training of all house staff will occur regarding the proper maintenance, disposal of and storage of medications. 01/01/2020 Implemented
SIN-00123283 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The first floor screen door is inoperable. The door does not close and it lets in insects.Windows, including windows in doors, shall be securely screened when windows or doors are open. The first floor screen door has been replaced (Attachment #3). Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. 08/24/2017 Implemented
6400.112(a)There was no documentation of a fire drill in July and September, 2016 An unannounced fire drill shall be held at least once a month. The assistant trainer is responsible for tracking firedrills each month to ensure that all homes complete an unannounced drill as required. The assistant trainer will alert the Regional Director by the 20th of each month of any drills still not completed. The assistant trainer will notify the Associate Directors and Program Coordinators of drills needed to ensure drills are completed by the end of the month. The assistant trainer will send follow up emails on the 25th and last day of each month until all outstanding firedrills are turned in. All management staff were trained in fire safety and Delta¿s procedures on 10/13/2017 (Attachment #2) 10/13/2017 Implemented
6400.112(e)The previous sleep drill occurred on 8/16/16 and the most recent sleep drill occurred on 3/22/17.A fire drill shall be held during sleeping hours at least every 6 months. The assistant trainer is responsible for tracking firedrills each month to ensure that all homes complete an unannounced drill as required. The assistant trainer will alert the Regional Director by the 20th of each month of any drills still not completed. The assistant trainer will notify the Associate Directors and Program Coordinators of drills needed to ensure drills are completed by the end of the month. The assistant trainer will send follow up emails on the 25th and last day of each month until all outstanding firedrills are turned in. All management staff were trained in fire safety and Delta¿s procedures on 10/13/2017 (Attachment #2) 10/13/2017 Implemented
SIN-00266372 Renewal 05/15/2025 Compliant - Finalized
SIN-00061192 Renewal 02/18/2014 Compliant - Finalized