Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288731 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 completed Initial Medication Administration Training; however, annual course renewal records were incomplete and did not include two (2) Practicum Observations and two (2) MAR Reviews.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).Initial date was 5/23/2019, Med Obs & MAR Reviews 2025 & March 2026 06/12/2026 Not Implemented
6400.169(d)There was no record to support that Staff #2 completed and passed Initial Medication Administration Training.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.Termed on 4/19/2025 06/12/2026 Implemented
SIN-00285193 Unannounced Monitoring 03/17/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bedroom and kitchen door have a buildup of dirt; the oven and microwave need cleaning.Clean and sanitary conditions shall be maintained in the home. The bedroom and kitchen doors, oven, and microwave were thoroughly cleaned on 3/17/26. The home was inspected to ensure all areas met cleanliness standards. 03/17/2026 Implemented
SIN-00266377 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dresser in the rear right bedroom was missing several knobs or handles rendering the drawers difficult to open Furniture and equipment shall be nonhazardous, clean and sturdy. Knobs were added to dresser by maintenance technician on May 27, 2025 (attachment #11) 05/16/2025 Implemented
SIN-00224309 Renewal 05/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(2)There are items of clothing and other belongings throughout individua#1l's bedroom. Access to the bedroom was limited, due to the large amount of clothing, totes, and boxes in the bedroom. The current state of the individual's bedroom creates a potential health and safety hazard. The staff stated they are in the process of purging the individual clothing and books.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. "Associate Director schedule to visit individual#1 on 5/15/23 and supported him in organizing his bedroom. Associate director and Individual #1 organized clothing and other items to make more space and increase access. Individual#1 was willing to receive support from the associate director in cleaning and allowed for assistance to organize and reduce the amount of totes and boxes. Individual#1 agreed that they were willing to receive support 2 times per week from staff to organize and clean the room. ""Support"" was explained as verbal reminders and physical assistance. accompanying photos labeled 6400.81k-quincy1 6400.81k-quincy2 6400.81k-quincy3 6400.81k-quincy4 6400.81k-quincy5" 06/30/2023 Implemented
SIN-00166426 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom had unsanitary conditions such as soiled bedding, food particles under the bed, wrappers and other debris all over the room.Clean and sanitary conditions shall be maintained in the home. Team met with Individual #1on 10/18/19 and he agreed to clean his room with assistance. Storage tubs were purchased and staff assisted Individual #1 in organizing his room. (Attachment #26) Staff will encourage Individual #1 to clean his room on a weekly basis. 11/19/2019 Implemented
6400.111(f)The Fire Extinguisher located in the attic has not been inspected annually, last inspected 01/2017. 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 9/12/19. (Attachment #27) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
SIN-00075965 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 #2's, date of hire 9/8/14, criminal history check was completed on 9/15/14. 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.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. 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. 03/02/2015 Implemented
SIN-00047518 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)On 3/7/12 and 4/4/12 and 6/14/12 and 7/11/12 and 9/13/12, 10/8/12, 11/13/12, 12/13/12, 1/3/13, 2/4/13 and 3/12/13 the front door was used for monthly fire drills.(f) Alternate exit routes shall be used during fire drills. We have revised fire drills forms to note alternate exits used. Staff training held on 4/5/2013. PD will monitor monthly use of alternate exits. 04/22/2013 Implemented
SIN-00140942 Renewal 08/15/2018 Compliant - Finalized