Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261930 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)An individual living at this home requires poisons to be locked as per the information in the ISP. There were dishwasher pods and cleaning supplies found unlocked in the kitchen under the sink, dish soap on top of the sink, a bleach tablet for the toilet in an unopened package on the shelf in the individual's bathroom and personal care soap, bodywashes, shampoos, toothpaste, and mouthwash also unlocked in the individual's bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaning supplies were locked up on 3/4/2025 in the cabinet under the sink. All of the individual's personal care items were locked up on 3/4/2025. 03/04/2025 Implemented
6400.64(a)The air fryer located in the kitchen of the home has not been cleaned. When a hand was touched to the front drawer area of the air fryer, grease dripped out from the inside of the fryer to the outside onto the licensing representative's hand. There are brown stains of unknown origin on the shower floor in the bathroom located the master bathroomClean and sanitary conditions shall be maintained in the home. Staff cleaned the air fryer to be free of grease both inside and out. See attachment 4b.1 03/28/2025 Implemented
6400.64(a)Individual #3 has a large accumulation of garbage bags and containers of belongings on the floor of the bedroom that require cleaning and/or a plan to assist the individual with organizing. A review of the individual's ISP did not indicate that there is a plan for addressing/assisting the individual with storing and/or organizing collected items and keeping the bedroom clean and free of potential pest risks.Clean and sanitary conditions shall be maintained in the home. Assistant director reached out to Individual #3's SC to add into his ISP the documentation of his preference to move his belongings out of his closet and drawers into bags onto the floor. 03/28/2025 Implemented
6400.67(a)There were significant black scrapes that need painting on the outside (hall side) of the door of the bedroom door. There was an egg-sized hole in the wall of the one of the individual's bedrooms.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance order was submitted on 3/4/25. All work was completed by maintenance by 3/26/25. See attachment 4a 03/26/2025 Implemented
6400.77(b)There were no tweezers in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezers were replaced in the first aid kit on 3/26/2025. See attachment 4e 03/26/2025 Implemented
6400.82(f)There were no cloth or paper hand towels available for use in the upstairs hall bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Staff placed paper towels in the upstairs hall bathroom on 3/4/2025. See attachment 4f 03/04/2025 Implemented
6400.112(c)There was no documentation of the November 2024 Fire Drill, however there was documentation that the fire drill had occurred.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. November drill documented on form late. See attachment 4g 03/28/2025 Implemented
SIN-00240601 Renewal 03/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was unlocked bleach in the bathroom that was attached to the laundry room area. This was removed at the time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials, including cleaning supplies, will be locked up when not in use. The bleach in the bathroom was removed and disposed of on 3/6/24 at the time of inspection by the house supervisor. The department has protocols for storing all poisonous materials. 03/21/2024 Implemented
6400.181(c)The current annual assessment completed on 8/26/23 for Individual #3 is identical to the previous year's assessment completed on 8/26/22, so therefore was not based on current documentation and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The annual assessment for individual #3 has been re-written on 3/21/24 utilizing the new annual assessment form which was updated based on the 6400 regulations and will be based on assessment instruments such as interviews, progress notes, and observations. 03/18/2024 Implemented
SIN-00220515 Renewal 03/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)A receipt was not provided for a purchase exceeding 15 dollars for individual 2. Individual 2 had a purchase for 178.51 dated 12/14/2022 with no attached receipt or invoice. 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. Receipts are required for transactions exceeding $15 if a home assumes responsibility of an individual's financial resources and records. The receipt for Individual 2 in the amount of $178.51 dated 12/14/22 was retrieved on 3/3/23 and submitted on 3/15/23 by the department Director. The department does have protocols and procedures for handling financial transactions. 03/17/2023 Implemented
6400.64(a)The shower floor of the master bathroom shower had residue consistent with dirt and individual 3's bedroom comforter was stained.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions must be maintained in the home; the shower floor of the master bathroom exhibited dirt residue. A work order was sent out on 3/15/23 by Director to the house Supervisor that included a request to clean the shower. The cleaning occurred and was inspected by the department Assistant Director/Supervisor on 3/16/23. The bedroom comforter of Individual 3 was stained. A replacement bed comforter was ordered and delivered with receipt of purchase submitted on 4/16/23 by the Director. The comforter was delivered to Individual 3's home. 03/23/2023 Implemented
6400.76(a)The two recliners in the living area were worn with minor tears and damage. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture and equipment in the home shall be nonhazardous, clean, and sturdy. Two recliners in the living area of the home were worn with tears and damage. Two new recliners were ordered by the Director on 3/9/23 and will be delivered to the home on 4/5/23. 03/16/2023 Implemented
6400.112(c)There is no indication is the smoke detectors were operable during the fire drill held on 1/28/23.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. There is no indication that smoke detectors were operable during 1/28/23 drill. All components of the fire drill record (form) must be completed during a fire drill. The house supervisor will run a fire drill, complete the form accurately and to completion including checking that all smoke detectors are operable. The drill will be completed no later than 3/27/23. The House Supervisor will perform the correction required. The Residential Director will obtain the copy of the completed fire drill form with a due date of 3/27/23. 03/27/2023 Implemented
6400.163(g)Levothyroxine 50mg tablets prescribed to individual 2 had a missing on pill count 12 which was inconsistent with all other medications. The pill likely fell out a small tear in the blister pack but it could not be determined where the extra pill was located.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Prescription medications shall be stored in an organized manner under conditions of sanitation, the Residential Assistant Director set up a system and trained the house Supervisor on 3/16/23 that included storage to eliminate the blister packs getting torn. 03/16/2023 Implemented
SIN-00201392 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff member#1's date of hire was 2/8/21, criminal check not completed until 2/17/22.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employee 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.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employee 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. Staff member #1¿s date of hire was 2/8/21, a criminal check was not completed until 2/17/22. DEC purchased the Employee Care Module from Sandata Technologies on 3/18/22. 03/18/2022 Implemented
6400.111(f)It could not be determined that the fire extinguisher on the second floor was inspected annually. The month and year of the inspection on the tag was not punched or marked. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. It could not be determined that the fire extinguisher on the second floor was inspected annually. The month and year of the inspection tag was not punched or marked. The fire extinguisher was removed on 3/2/22, at the time of inspection, and replaced with a properly tagged extinguisher, see attachment #2. All fire extinguishers were inspected and tagged on 3/8/22. 03/20/2022 Implemented
6400.144Verification that individual#1's Medical Doctor was contacted after the greater than 450 sugar reading on 2/28/2022 was provided but was not completed timely, the notification was not confirmed until the following day after discovery by licensing on 3/1/2022. There was an inadvertent logging of administration on 2/7/2022 of 4 units of Hemalog at noon. Sugar was read at 216 at the individual's day program and did not require a dosage. Agency stated no dose was given. The discrepancy was between the day program log and the Medication record.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. 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. Verification that individual #1¿s medical doctor was contacted after the greater than 450 sugar reading on 2/28/2022 was provided but not completed timely, the notification was not confirmed until the following day, after discovery by licensing on 3/1/2022. There was an inadvertent logging of administration on 2/7/22 of 4 units of Hemalog at noon. Sugar was read at 216 at the individual¿s day program and did not require a dosage. Agency stated no dose was given. The discrepancy was between the day program log and the medication record at the home. The Director retrained all staff on individual #1's insulin protocol, including when the PCP needs to be notified. They also received updated insulin training. Updated plans and instructions were printed and are located at the home for all staff who work with individual #1. 03/16/2022 Implemented
6400.165(c)Individual#1's Sugar reading measured at 478 prior to lunch on 2/28/2021 and documentation that the prescribed 5U (units) of Humalog was administered after reading was not provided. Verification of the sugar reading was provided but not the dose or the initials for the administration. The Day program stated administration was handled by residential program but it could not be verified who administered the required dose, if it was administered and the amount of the dose administered.A prescription medication shall be administered as prescribed.A prescription medication shall be administered as prescribed. Individual #1¿s sugar reading measured 478 prior to lunch on 2/28/21 and documentation that the prescribed 5U (units) of Humalog was administered after reading was not provided. Verification of the sugar reading was provided but not the dose or the initials for the administration. The day program stated administration was handled by residential program but it could not be verified who administered the required dose, if it was administered and the amount of the dose administered. There are staff at the day program who have completed insulin training. The Residential Program Specialist, Day Program, Program Specialist, and the Compliance Manager held a meeting on 3/8/22 to discuss options to have updated protocol information and to have an extra insulin pen to have at day program. An extra insulin pen was delivered to keep at individual #1's day program on 3/9/22, in the event that individual #1's blood sugar levels warrant a dose of insulin. The insulin is stored in a locked cabinet at the day program, in lieu of residential staff driving to the day program to administer insulin. An updated protocol was provided to the day program on 3/8/22. 03/09/2022 Implemented
SIN-00130362 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a broken table lamp on the dresser in individual #1's bedroom. It had a broken bulb where pieces had fallen onto the dresser. The light was removed during inspection. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture and equipment shall be nonhazardous, clean, and sturdy. The lamp in individual #1¿s bedroom was removed during inspection on 01-30-2018. The house supervisor and all staff were retrained on 3-23-18 in completion of daily walk thru of the site to check for broken items and other potential hazards. The shift checklist has been updated. 04/15/2018 Implemented
6400.105There were 26 cans of various house paints stored in the room where the heating unit was located.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. All paint cans were removed from the heat source and relocated to a separate room. The house supervisor was retrained on 03-23-18 in the completion of site observations to ensure all floors, walls, ceilings, and other surfaces are in good repair. 03/23/2018 Implemented
SIN-00107138 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)There was no receipt in Individual #1's financial record for a disbursement of $150.00 on 03/24/2016. 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 15.00 dollars made on behalf of the individual carried out by or in conjunction with a staff person. If the home assumes the responsibility of maintaining an individual's financial resources, the following will be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding 15.00 dollars made on behalf of the individual carried out by or in conjunction with a staff person. Due to a filing issue, receipts where separated from the log and found in the bottom of the filing drawer. All receipts will be required to be turned in an envelope to ensure they do not get separated. Attached is receipts and log. A full financial file review will be completed by the CRD Director by 4/15/2017. The Residential Coordinator will ensure receipts are secure in an envelope when turned in to the financial office for review and filing. Attachment #8 04/15/2017 Implemented
6400.64(a)There were over a dozen of insects, mostly silverfish, and several inches of an unknown liquid in a five gallon bucket located in the furnace room in the basement.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home. The bucket with salt and silverfish were removed from the basement. Attached is a the procedure that was written and the site safety for all homes for February to include checking all locked areas. CRD Director and/or ACRD Director responsible for ensuring site safety checklist are done correctly and any areas of non compliance are corrected immediately. Clarification of clean and sanitary conditions will be added to the monthly safety list. Attachment #7. 02/28/2017 Implemented
6400.80(b)There was a broken and bent portion of the fence approximately fifteen feet in length found in the backyard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The outside of the building and the yard or grounds will be well maintained, in good repair and free from unsafe conditions. The fence was repaired. As the tree fell the morning of the inspection, it was unable to be addressed immediately. It is DEC's policy to fix areas of need of repair within 24 hours of being informed of the need. This policy will stay in place. Attachment #7 02/03/2017 Implemented
6400.105A can of rustoleum appliance epoxy ultra hard enamel, which is flammable was stored within five feet of the furnace in the basement. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Flammable and combustible supplies and equipment will be utilized safely and stored away from heat sources. Maintenance Manager removed the can and completed a safety check in all homes. All staff will be retrained in site safety checklist and their responsibility to ensure compliance. CRD Director will track corrections and conduct unannounced inspections. February 2017 site safety checklist attachment #6 02/28/2017 Implemented
6400.162(a)Individual # 1's medication box contain Glucose tablets which did not have a pharmaceutical label. The medication administration record for Individual # 1 documents mupiricin ointment is prescribed for daily use to be applied to the face as well as PRN use to be apply to other parts of the body. The pharmaceutical label on mupiricin ointment documents only the daily use and not the PRN use.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The original container for prescription medications will be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Full medication review was completed at all sites; all medications have original labels. House Supervisors to do through check weekly and overnight staff nightly. Residential Coordinator is responsible to review at least monthly. February 2017 review attached. Attachment # 5 02/28/2017 Implemented
6400.164(a)Individual # 1's medication box contained Glucose Tablets which were not listed on the medication administration record. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin will be kept for each individual who does not self-administer medication. Medication log was corrected and the medication in question was clarified. Ongoing monitoring of the medication logs will be the responsibility of the program supervisor and residential coordinator. February 2017 log attached to show correction was completed. Medication Mar and monitoring added to Supervisors checklist that is submitted weekly. Attachment #4 02/28/2017 Implemented
6400.181(e)(12)Individual # 1's annual assessment dated 12/19/2016 did not document recommendations for training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment will include the following information: Recommendations for specific areas of training, programming and services. Program Specialist was retrained in the needs of the assessment and will participate in program specialist meetings to review assessment requirements. The CRD Director will review the assessments to ensure compliance. All assessments were reviewed and corrections made and completion date was 3/1/2017. Attached is a copy of the revised assessment and training sign in form. Attachment #2 & #3. 03/21/2017 Implemented
SIN-00086984 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The entertainment center in Individual #1's bedroom was covered with dust. Furniture and equipment shall be nonhazardous, clean and sturdy. The entertainment center in individual #1's bedroom was cleaned on 11/19/15. Furniture and equipment shall be nonhazardous, clean and sturdy. During house meetings, individuals reminded to inform staff of furniture needing repaired in their bedrooms. For the individuals that locked their rooms, staff will ask to complete the site safety checklist with them on a monthly basis. Addendum #5. 12/01/2015 Implemented
SIN-00084602 Unannounced Monitoring 04/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)Staff #1 yelled at the individuals in the home when it was discovered that there was no bread in the house. Individual #1 was clearly upset with the treatment from Staff #1.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Investigation revealed that staff #1, had in fact, begun to yell when he discovered that there was no bread in the house. Individual #1 became upset. Two out of five individuals did hear staff #1 yell. No other individual heard staff #1 make a threat. It was recommended that staff #1 receive a progressive written notice regarding his behavior. Recommendations were also made to relocate staff #1 to another residence. Staff #1 would be re-trained on verbal and anger/stress management. All agency staff will receive this training twice yearly as well. All residents at all locations will review these trainings and discuss at house meetings. At all residential programs, a white board will be added and staff will be required to note on the board what food items are needed in the home. Residential supervisor will check the refrigerator when they come to each location to ensure that the needed supplies are on hand. * It should be noted that staff #1 resigned his position within days of reinstatement. 01/15/2016 Implemented
SIN-00063495 Renewal 07/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The base board in the first floors power room were rusted. The base boards in the second floor bathroom were rusted. The handrail leading from the second floor exit is rusted. Floors, walls, ceilings and other surfaces shall be free of hazards.Floors, walls, ceilings and other surfaces shall be free of hazards. Rust has been added to the site safety checklist that is completed monthly. Therefore if any rust is present it will be reported via the site safety inspection and maintenance will corrected as needed. All work was started on 7/2/2014 and completed by 9/16/14. 09/16/2014 Implemented
6400.186(b)Individual #4's ISP review dated 5/22/14, was not signed by the program specialist. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. ISP reviews will be signed by program specialist and individual. Program Specialist disseminated this review via electronically but did not print and sign for file. Program Specialist re-trained in the need to print and sign and get to file in a timely manner. The program specialist and the CRD Director will complete monthly sample file reviews. These reviews will include both medical and programming components and ensure all ISP reviews are signed as required. The file reviewed occurred on August 26, 2014 and September 26, 2014 and will continue monthly by the CRD Director and PS. Individual #4's file was reviewed compliant and all ISP reviews were signed and dated. 08/26/2014 Implemented
SIN-00049757 Renewal 07/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Sleeping hour fire drills were not held between 11/28/12 and 7/1/13. (e) A fire drill shall be held during sleeping hours at least every 6 months. In review a fire drill was held on March 11. 2013 and was misfiled. The fire drill was held on March 11, 2013 and verified with protection one on March 22, 2013 which was noted by TB the administrative assistant. It also was noted in the daily log at the site on March 11, 2013 by 2 different employees that it was completed. Fire drills are kept in a red ring binder and in preparation for the inspection they were place in the licensing file. It was during the transfer of the paperwork that it was misfiled. There were 2 fire drills held that month so it was not noted that it was misfiled and we were unaware that it was not in file until exit interview. This was a misfiling issue and not a matter of not completing drill. Additionally, during the self inspection on April 24, 2013 this drill was present as noted on the LII score sheet. 08/01/2013 Implemented