Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274323 Renewal 09/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(II)On 9/24/2025 at 12:20PM, Individual #1's bed was observed with bilateral upper bedrails that had the potential to restrict the movement or function of Individual #1's body. Individual #1's current order, dated 1/15/25, for the bedrails for "client safety" was completed by the agency's Certified Registered Nurse Practitioner. Staff interviews reveal that Individual #1 is unable to easily remove the device or indication or request the immediate removal by a staff person. The agency has not made a determination that the bedrails are not a mechanical restraint or medically needed to include but not limited to the completion of the "mechanical restraint decision tree" and the attempted use of alternative devices.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.For individual #1 identified in the deficiency, the POC must outline specific, immediate corrective actions. Individual Functional and Risk-Benefit Assessment The agency will conduct a new, comprehensive assessment for individual #1, with input from their physician and parent and/or guardian. This assessment will specifically identify the medical symptom or functional need (e.g., mobility assistance, repositioning) that the bed rails address. The assessment will be documented on the agency's standardized form and reviewed by nursing for completeness and accuracy. Medical Order Review A licensed nurse will verify that a valid, current physician's order is in place for individual #1 using bed rails. The order will specify both the type of rail and the medical symptom or diagnosis for which the bed rail is prescribed. This order will be kept on file in the resident's record and renewed annually, or sooner if there is a change in the individual's condition. ISP and HRST Update The resident's Individual Support Plan (ISP) will be updated to include the identified need for the use of bed rails, ensuring that the intervention is integrated into the person's overall plan of care and treatment supports. The resident's Health Risk Screening Tool (HRST) will also be updated to reflect the use of bed rails and the diagnosis or medical condition that necessitates their use. The assigned Program Specialist will ensure that updates are submitted to the Supports Coordinator, and nursing will verify HRST accuracy. Entrapment Mitigation Any bed rails in use will be inspected to ensure they meet manufacturer specifications and entrapment prevention standards consistent with FDA Hospital Bed Safety Workgroup (HBSW) guidelines. Informed Consent Informed consent for the use of bed rails will be reviewed and reaffirmed with the resident or their parent and/or guardian, confirming understanding of both the risks and benefits. Consent will be re-reviewed annually or with any change in the individual's condition. Documentation Review The care plan will be updated to clearly identify the medical indication for the bed rail and detail how its use assists the resident's condition. The care plan will be reviewed and updated as needed and at least annually, in conjunction with the functional and risk-benefit assessment. 12/01/2025 Implemented
SIN-00236126 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1 is prescribing the following medications that did not include the diagnosis or purpose on the December 2023 Medication Administration Record: HM Milk of Magnesia with directions to give 30 ML via G-Tube every day and J & J Baby Shampoo with directions to use for lid wipes every day.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The community home nurses have ensured that a diagnosis or purpose has been included in the medication record for each individual who has any prescription medication or treatment administered, including pro re nata. Completed 12/19/2023 12/19/2023 Implemented
6400.207(5)(III)On 12/13/23, at 1:01 PM, Individual #2 had full bed rails that restrict the movement or function of their body, and at 1:06 PM that Individual #1 had full bed rails that restrict the movement or function of their body.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Individual #1 was given a physician¿s order for the use of a hospital bed with side rails for safety and protection from injury, secondary to their diagnoses of cerebral palsy, spastic quadriplegia, and blindness. Individual #1 would have their side rails disengaged/lowered by a staff person upon individual #1¿s indication. Individual #1¿s plan allowed for periodic removal of the side rails for freedom of movement. Individual #2 was given a physician¿s order for the use of a hospital bed with side rails for safety and protection from injury, secondary to their diagnoses of spastic diplegia, osteoporosis, blindness, and seizure disorder. Individual #2 can and would have their side rails disengaged/lowered by a staff person upon individual #2¿s indication. Individual #2¿s plan allows for periodic relief of the side rails for freedom of movement. 01/14/2024 Implemented
SIN-00199817 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental examination on 06/13/19, and then again on 04/27/21An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. In response to this violation of 6400.142(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the community home nurses shall be trained to schedule dental examinations for all residents of the community home program (18 years of age or older) that will occur annually with those residents¿ current dental provider. [Training on scheduling dental appointments, dated 3/31/22, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. 03/09/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 02/20/21. The rights document did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, control of and the right to refuse the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.In response to this violation of 6400.34(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, and into the future, when explaining to and informing each individual of their rights, the individual will be informed of the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions. The updated rights will be documented for each individual who resides within our community home program and their guardians, and they will be asked to sign off that they have had these rights explained to them. This will all be completed no later than April 15, 2022. [Updated and signed Individual Rights document, dated 3/28/22, received on 4/4/22 and reviewed 4/19/22. Training, dated 3/29/22, on Individual Rights received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. 04/15/2022 Implemented
SIN-00096260 Renewal 11/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital and ambulance were not on or by the telephones in the home.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 telephone number for the police was added to every phone with an outside line in addition to the numbers for fire, ambulance, the nearest hospital and the poison control center. A copy of the new postings were given to the inspector prior to the end of the survey. The Community Home Managers will inspect the phones monthly and document this on the Monthly House Inspection. The monthly house inspections are reviewed by the Program Specialist and the Director and Assistant Director of Community Homes. 07/02/2016 Implemented
SIN-00086750 Unannounced Monitoring 10/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.17HCSIS incident #7837465 regarding alleged abuse/improper or unauthorized use of restraint, involving Individual #1, date of birth 6/8/98, occurred at approximately 4:00 PM on 10/21/15 but was not reported to Child Line until approximately 11:45 AM on 10/22/15.The home shall immediately report abuse or suspected abuse of an individual 17 years of age or younger to Child Line (800) 932-0313. All Community Home Program Specialist, managers, nurses and behavior specialists will be in-serviced on the McGuire Memorial Incident Management Policy as well as the requirements in accordance with the Pennsylvania Child Protective Services recognizing and reporting child abuse training for mandated reporters.[Within 3 months of receiving the Licensing summary, all agency staff will be trained by outside source on immediate mandate reporting inaccordance with APS, OASPA and Child Protective Services. (AS 12/28/15)] 12/09/2015 Implemented
6400.33(a)On 10/21/15, at approximately 4:00 PM, Direct Service Worker #1 reportedly grabbed Individual #1 by the arm and forced him/her to go outside; Individual #1 pushed back. Direct Service Worker #1 reportedly "jacked (Individual #1) up against the wall" and put his/her arm against Individual #1's neck and yelled, "I'm not gonna put up with this." Individual #1 appeared upset and was crying. During the course of this investigation, it was also reported to the Licensing Representative by staff that there had been other occasions in which Direct Service Worker #1 had been "physically forceful", "aggressive" and "verbally loud" towards Individual #1. It was reported that Direct Service Worker #1 would "power over" Individual #1 and forcefully take the individual to the door to go outside. These incidents were not reported for "fear of retribution" as Direct Service Worker #1 would become "very confrontational" and "physically intimidat[ing]."An individual may not be neglected, abused, mistreated or subjected to corporal punishment. All Community Home staff working in the home were in-serviced on the reporting requirements in accordance with the Pennsylvania Child Protective Services Recognizing and Reporting Child abuse training for Mandated Reporters. All staff were also in-serviced on the confidentiality, abuse and neglect training.[In addition to annual trainings, within 3 months and continuing every three months for 1 year of receiving the Licensing summary, all agency staff will be trained by on abuse prevention and positive approaches. At least one of these trainings will be from an outside source. (AS 12/28/15)] 11/23/2015 Implemented
SIN-00217285 Renewal 01/10/2023 Compliant - Finalized
SIN-00147209 Renewal 12/18/2018 Compliant - Finalized
SIN-00100182 Unannounced Monitoring 08/25/2016 Compliant - Finalized