Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288743 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 last certification date was on 12/30/24. There was Only 2 observations/no MAR reviews/did not complete the annual medication training. Staff #2's last completed practicum was on 3/21/24. Staff #3's last certification date was on 8/15/2018.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 Termed on 3/8/2026 Staff #2 Termed on 3/16/2026 Staff #3 Took ODP recertification course on 8/15/2018, 2 Med Obs & MAR Reviews for 3/29/2025, 10/3/2025 06/12/2026 Not Implemented
SIN-00224308 Renewal 05/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)There was evidence of infestation (insects) in the basement.There may not be evidence of infestation of insects or rodents in the home. old bug trap was removed 5/15/2023 by Regional Director. Pest control services conduct regular quarterly, and more frequently as needed, visits to Lantern Lane. Supporting documentation labeled 6400.64b-Ehrlich Contract, Ehrlich Invoice-Lantern, and 6400.64b 06/30/2023 Implemented
6400.77(b)No antiseptic 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. new first aid kit was placed in the home with all required items available on 5/11/2023 by the Regional Director. Supporting documentation labeled 6400.77b-lantern 06/30/2023 Implemented
6400.110(a)No operative smoke detector was in the basement, the one there did not have a battery. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Smoke detector battery replaced by Regional Director, was tested, and is operable. Supporting documentation 6400.110a-lantern1 06/30/2023 Implemented
SIN-00187736 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)There was no verification that staff 1 Received initial site specific fire safety training by a fire safety expert upon the hire date of 3/30/20. General fire safety training was completed on 4/23/20 after date of hire.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.The training department is scheduling the Train the trainer training for all management staff. Once the Management staff have been trained as trainers, they will train each new hire in the site specific fire safety training requirements upon hire. 08/01/2021 Implemented
SIN-00123289 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The basement shower had about 4 ft wall portion missing to the right of the shower and two foot wall portion missing to the left of the shower. The basement wall has a 1 foot portion missing around its perimeter. The basement vinyl floor has a 2 foot tear under the window.Floors, walls, ceilings and other surfaces shall be in good repair. The area of the basement with missing portions of the wall and with missing portions of the vinyl flooring is not currently used by staff or individuals. The facilities department has placed a locked door knob on the door so the room cannot be accessed by the individuals. (Attachment #14) There is no means of egress in this portion of the basement. 08/08/2017 Implemented
6400.71Emergency phone numbers did not include the nearest police and fire department.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The template for emergency numbers posted by each phone has been revised to include the name and numbers for the nearest police and fire department for non emergencies (Attachment #13). 911 will still be posted for all emergency calls. 11/20/2017 Implemented
6400.112(a)There was no documentation of a fire drill in June, 2007. 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-00075962 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 #7's, hired on 12/1/14, criminal history check was completed on 12/5/14.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. 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. 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. 03/02/2015 Implemented
SIN-00266376 Renewal 05/15/2025 Compliant - Finalized
SIN-00140939 Renewal 08/15/2018 Compliant - Finalized
SIN-00061197 Renewal 02/18/2014 Compliant - Finalized