Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288744 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 initial training packet on 1/24/25 was not complete. Staff #2's last certification date was on 11/7/22.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 Working in Community Center, trained by 6/5/2026. On-site observations in progress Staff #2 Initial cert date occurred 11/7/2022, 2025 Med Observations & MAR Reviews occurred 3/15/2025 and 9/7/2025 06/12/2026 Not Implemented
SIN-00266373 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dryer vent was detached from the back of the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. The dryer vent was reattached by Delta maintenance personnel and evidence provided to the lead inspector on 5/15/25. (attachment #1) 06/15/2025 Implemented
SIN-00210931 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The following medication was not present in the medication box of Individual 1: Ammonium Lac 12%: Apply to arms twice daily for dry skin. They did have a bottle of PRN Ammonium Lac available in the medication box but not the one prescribed for daily administration.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Ammonium Lac 12% was located in the bathroom on 8/30/2022 and returned to the locked medication box by residential coordinator on same day (Attachment #29). 08/30/2022 Implemented
6400.166(b)ChapStick prescribed to Individual 1 was not documented as being administered on 8/12/22 for 4pm administration time.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Residential coordinator updated the MAR with corrections on 8/30/2022 (Attachment #30). Residential coordinator contacted staff to review medication documentation on 8/31/2022. 08/30/2022 Implemented
SIN-00123285 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The porch located outside he second floor has a deterated wooden handrail wit visiblr nail pops. Individual # 1's bedroom is significanntly stained and needs to be cleaned or replaced.Clean and sanitary conditions shall be maintained in the home. The porch on the second floor has been repaired and painted 08/09/2017 (Attachment #9). The carpet in individual # 1¿s bedroom has been cleaned 08/17/2017 (Attachment #6). 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. 08/17/2017 Implemented
6400.67(a)The kitchen vinyl floor covering has 4 vinyl tiles eithher torn or missing. The step carpeting between the first and second floor is torn and presents itself as a tripping hazard. The bathroom tub caulking has portions missing resulting in the presence of mildew.Floors, walls, ceilings and other surfaces shall be in good repair. The kitchen vinyl flooring has been replaced 08/30/2017 (Attachment #6). The carpeting on the stairs has been removed and replaced with treads 08/23/2017 (Attachment #7). The caulk and mildew has been removed, cleaned, and recaulked 08/21/2017 (Attachment #8) 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. 08/30/2017 Implemented
SIN-00091504 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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 #39's date of hire was 05/11/2015 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-00061194 Renewal 02/18/2014 Compliant - Finalized