Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251392 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment of the home, completed date 4/15/24, indicates violations for 6400.18(g)-(j6) and 6400.19(a)(1); however, there was no written summary of corrections made.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. All Mainstay Life Services licensed residential managers and coordinators (management staff) will complete a training on how to complete the self-assessments to meet the compliance standards. This will include what fields cannot be marked as "NA," and what needs to happen when something is found to be in violation. This training will take place by February 28th, 2025, and will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was discussed). The reason the training will occur in February is the self-assessments are done in March, so this will be a good time to review the requirements of the self-assessments. 02/28/2025 Implemented
6400.181(e)(12)Individual #1 had an assessment completed on 2/7/2024, however the assessment indicated no recommendations for training, programming, or services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Staff will be retrained on annual assessment and the expectations by January 31st, 2025, and this training will be conducted on an annual basis thereafter. The training will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was discussed). This training will be completed by January 31st, 2025. 01/31/2025 Implemented
6400.166(a)(10)Individual #1's 8:00 PM Risperidone 1mg tablet was not included on the September 2024 Medication Administration Record (MAR) but was administered 9/1 through and including 9/4/24 at 8:00 PM.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Mainstay Life Services will conduct a training with all management staff on keeping the Medication Administration Record in compliance with ODP regulations. The training will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was taught). This training will be completed by November 30th, 2024. 11/30/2024 Implemented
6400.166(b)Individual #1's 8:00 pm Risperidone 1mg tablet was administered but not initialed by staff persons administering the medication on 9/1/2024 through and including 9/4/2024 at 8:00 PM. The 8:00 PM dose of the medication was not indicated on the September 2024 Medication Administration Record (MAR).The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Mainstay Life Services will conduct a training with all management staff on keeping the Medication Administration Record in compliance with ODP regulations. The training will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was taught). This training will be completed by November 30th, 2024. 11/30/2024 Implemented
6400.213(1)(i)Individual #1's record did not include religion, as required by 6400.213(1)(iv). Individual #1's record did not include identifying marks, as required by 6400.213(1)(ii)Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Including this information will be the responsible of the Intake and Referral Specialist, a position that Mainstay Life Services hired for just this year to manage referrals and help facilitate the intake process. This person will include all the information during the intake and referral process, so it is in place before the person starts with their program. Evidence will be the Intake and Referral Manual which governs our intake processes. This update will be made by January 31st, 2025. 01/31/2025 Implemented
SIN-00230514 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)During the physical site inspection conducted on 9/07/2023, three bottles of "Surface Disinfectant and Deodorant" as well as a bottle of "Lemon Furnisher Polish" were located unlocked under the sink in the bathroom located on the top floor. The individual who resides in the home is not assessed safe with poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. All residential staff and supervisors will be retrained on the requirement that poisonous materials shall be kept locked or made inaccessible to individuals. This training will be done at monthly staff meetings. [Additional information received from the agency via email on 10/4/23: Residential staff and supervisors will be trained on the requirement that poisonous materials be kept locked and inaccessible to individuals during "November staff meetings." Home Safety Checklists will be completed by program managers on a quarterly basis and reviewed by program coordinators. DPOC by HDKP, HSLS, on 11/1/2023]. 09/26/2023 Implemented
6400.51(b)(1)Direct Service Worker #1, date of hire 10/31/2022, did not complete the following orientation training: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Mainstay's new training manager will ensure that all new employees complete all required trainings during there orientation class. They will utilize orientation checklists to make sure all trainings are completed before a new employee leaves orientation. [Additional information received from the agency via email on 10/4/23: The hired Training Manager is anticipated to start on 10/2/23. The Training Manager will be trained on orientation and annual training requirements for all staff on or about 10/3/23. Administrative and supervisory staff will be trained on orientation and annual training requirements for staff on or about 10/10/23. DPOC by HDKP, HSLS, on 11/1/23]. 09/26/2023 Implemented
6400.51(b)(2)Direct Service Worker #1, date of hire 10/31/2022, did not complete the following orientation training: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.Mainstay's new training manager will ensure that all new employees complete all required trainings during there orientation class. They will utilize orientation checklists to make sure all trainings are completed before a new employee leaves orientation. [Additional information received from the agency via email on 10/4/23: The hired Training Manager is anticipated to start on 10/2/23. The Training Manager will be trained on orientation and annual training requirements for all staff on or about 10/3/23. Administrative and supervisory staff will be trained on orientation and annual training requirements for staff on or about 10/10/23. DPOC by HDKP, HSLS, on 11/1/23]. 09/26/2023 Implemented
6400.51(b)(4)Direct Service Worker #1, date of hire 10/31/2022, did not complete the following orientation training: Recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Mainstay's new training manager will ensure that all new employees complete all required trainings during there orientation class. They will utilize orientation checklists to make sure all trainings are completed before a new employee leaves orientation. [Additional information received from the agency via email on 10/4/23: The hired Training Manager is anticipated to start on 10/2/23. The Training Manager will be trained on orientation and annual training requirements for all staff on or about 10/3/23. Administrative and supervisory staff will be trained on orientation and annual training requirements for staff on or about 10/10/23. DPOC by HDKP, HSLS, on 11/1/23]. 09/26/2023 Implemented
SIN-00069650 Renewal 09/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was used 11 times by all individuals for fire drills conducted September 2013 through September 2014.Alternate exit routes shall be used during fire drills. The policy has been amended to include the statement "All individuals in the home must use every exit that they are physically able to use". Forms have been developed to make it apparent which exits have been used as the year progresses. All staff will be retrained on the new policy by their manager during the December and January staff meetings. The individuals currently living in this home use wheelchairs and are unable to evacuate using alternate exits. 11/07/2014 Implemented
SIN-00179478 Renewal 11/17/2020 Compliant - Finalized
SIN-00119667 Renewal 08/14/2017 Compliant - Finalized