Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00166424 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The blinds in individual #1's bedroom were damage and not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The blinds in Individual #1's bedroom have been repaired on 9/24/19. (Attachment # 25 ) 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
6400.112(g)The fire drills were not held on different days with 8 of 12 drills held on Thursday (8/29/19, 7/17/19, 6/6/19, 5/23/19, 1/10/19, 9/13/18, 10/4/18, 12/20/18) Fire drills shall be held on different days of the week and at different times of the day and night. Fire Drill form will be modified to ensure different times and locations are completed for monthly fire drills. Going forward, fire drill requirements will be documented and tracked monthly by the administrative office clerical staff and monitored by the Regional Director. 02/01/2020 Implemented
SIN-00123286 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Floor carpeting was missing near the entrance to the boiler room.Floors, walls, ceilings and other surfaces shall be in good repair. The carpeting in the front entrance to the boiler room has been replaced (Attachment #11). 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. 09/01/2017 Implemented
6400.67(b)The boiler room has exposed wires and it was not enclosed in a metal box. Floors, walls, ceilings and other surfaces shall be free of hazards.The exposed wires have been covered and secured with an electrical box (Attachment #12) 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. 08/14/2017 Implemented
6400.111(c)The fire extinguisher was located in the laundry area but none was located in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). The fire extinguisher was moved from the laundry room into the kitchen (Attachment #10). Going forward the Associate Director will check fire extinguisher locations during required monthly walkthroughs of each site as well as during the physical site self assessment. Facilities will be notified to change the location of any fire extinguishers that are not in the correct location. 08/03/2017 Implemented
6400.112(a)There was no documentation of a fire drill in June of 2017. 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
SIN-00075959 Renewal 02/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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 #8's, hired on 12/15/14, criminal history check was completed on 12/17/14.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.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. 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. 03/02/2015 Implemented
SIN-00224306 Renewal 05/09/2023 Compliant - Finalized
SIN-00187735 Renewal 05/12/2021 Compliant - Finalized
SIN-00061195 Renewal 02/18/2014 Compliant - Finalized