Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288732 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 #2 annual practicum only had one MAR review and one observation on 12/20/2025.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).Termed on 5/30/26 06/12/2026 Not Implemented
6400.169(d)There was no record to support that Staff #1 completed and passed Initial Medication Administration Training. The course sheet on file was incomplete and did not reflect individual test scores or trainer signature.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Staff #2 was retrained on the initial medication training curriculum 5/12/2026 & 2 Med Observations 5/16/2026 06/12/2026 Implemented
SIN-00266375 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)Fire extinguisher in the pull-down attic had not been inspected in greater than 1 year. Documentation has been provided that the particular extinguisher has been replaced with a recently inspected 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. Fire extinguisher was replaced on May 16, 2025. Evidence of updated extinguisher submitted to lead inspector (attachment #9). 05/16/2025 Implemented
6400.144Individual #3 is prescribed the medication Metoprol Tab 25mg -- Give 1 tablet by mouth twice a day if systolic BP is 120 or greater. On 5/6/25 the medication was administered when systolic was 119. The medication was administered every day in May, however there were only documented blood pressure readings on 5/5, 5/6, 5/7, 5/10, and 5/12. The blood pressure needs to be taken and documented prior to administering the medication in order to verify proper administration and compliance.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. New blood pressure medication book was created by Delta LPN (attachment #8) with AM and PM blood pressure readings and staff were educated to follow directions on pharmacy label and document blood pressure (attachment #10) 05/16/2025 Implemented
6400.165(b)Three medications prescribed to Individual #3 were not present at site: Alubterol Nebulizer - PRN Acetaminophen 325 - PRN NYStatin Cream 100000 - PRNA prescription order shall be kept current.Tylenol was delivered to the home on 5/16/25. 05/16/2025 Implemented
SIN-00091507 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff # 13's initial medication administration training was invalid as the trainer did not completed the paperwork. 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 # 14's annual medication administration training dated 11/03/2015 was invalid as the fourth MAR review was completed on 12/08/2015.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
SIN-00075961 Renewal 02/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The first floor laundry room has a water damaged ceiling with loose tape and plaster debris. Floors, walls, ceilings and other surfaces shall be in good repair. The ceiling was repaired on 3/9/15. Our internal process is to complete work orders for facility maintenance concerns. We will continue to follow our process. The Program Specialist will check the home on a monthly basis to ensure that the home is in good repair. 03/09/2015 Implemented
SIN-00285192 Unannounced Monitoring 03/17/2026 Compliant - Finalized