Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261616 Renewal 03/04/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(f)Individual # 1 is allotted $40 per week to spend and has an up to date personal finance record. If the money is not spent, the balance is forwarded to a single checking account for both housemates and ALL individuals in the agency. This is commingling of individual funds with others (in the home) since all money not spent are deposited into a single agency checking account.There may be no commingling of the individual's personal funds with the home or staff person's funds. The provider will revise the "Management of Personal Assets" policy for client funds to include the creation of an individual checking account for each resident for whom the provider serves as representative payee. Each resident will have a separate account, with all deposits and withdrawals made directly to and from their individual account. All monthly checks to individuals for whom the agency is representative payee are either sent directly to the agency for deposit or automatically deposited in the Individual checking account. Funds will not be transferred to a joint account and back to a resident account. 05/01/2025 Accepted
6400.62(c)A spray bottle with the hand written label "stove cleaner" was found under the kitchen sink.Poisonous materials shall be stored in their original, labeled containers. The stove cleaner was immediately secured during licensing on 3/5/25. All other poisonous materials were checked for proper storage throughout all sites. A mandatory training will be conducted by the Program Director for all staff to review the regulation, citation, and safety risk this presents to individuals with proper storage identified for each site. 05/01/2025 Accepted
6400.64(a)A golf ball size amount of lint was found in the dryer during the physical site walk through.Clean and sanitary conditions shall be maintained in the home. Notice signs will be posted near the laundry areas at all residential sites. (see document #4) A mandatory training will be conducted for staff to review the regulation, discuss citations from licensing, and explain the fire risk associated with leaving lint in the dryer. 05/01/2025 Accepted
6400.74Non skid surface was missing from the bottom two steps off of the back deck.Interior stairs and outside steps shall have a nonskid surface. Nonskid surface was placed on stairs on 3/14/25. (See document #6). A mandatory training will be conducted for all staff to review regulation, citation, safety risk this presents to individuals and staff expectation for notifying maintenance when a repair needs completed. Maintenance staff will receive an in-service to review the regulation, citation, and review the safety risk not having nonskid surface presents to individuals. Safety Committee Chair was notified of this citation. 05/01/2025 Accepted
6400.104Individual # 1 was recommended to use a wheelchair for all mobility on 10/01/24 by her Physical therapist due to an unsteady gait. An updated Fire department notification letter was not sent until 10/23/24.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. All Program Specialists and Healthcare team members will receive training on this regulation and violation to ensure fire letters are updated when individual assistance level is modified. Quarterly site audit form updated to include review of assistance needed for individuals and fire letter outline. 05/01/2025 Accepted
6400.214(b)Individual # 2 did not have a current assessment in the home during the physical site walk through. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The individual site books have been updated to include only the essential site information for each individual. All site books also have an electronic version stored in a shared Teams folder, allowing documents to be quickly printed and added to physical books when needed. (See document #3 for resident life plan book list) Individual books contain: 7. Resident information a. Personal information sheet b. Insurance cards c. Identification cards d. Current physical/annual exams e. Medication list f. Care protocols 8. Consents and Intake g. Money management h. Room and board i. Consents j. HIPPA 9. Medical consults/annual exam forms 10. ISP k. Current ISP l. ISP training sheets 11. Current Assessment 12. Current BSP/SEEN plans 05/01/2025 Accepted
6400.34(a)Individual # 1 was informed of her rights on 09/01/23 and not again until 09/19/24.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.The provider currently informs residents of their rights every year in September, but no specific due date was established. Moving forward, the provider will schedule the rights review one month before the previous year's review month to ensure that rights are reviewed within 365 days. (Example: year 2025 will occur in August, year 2026 will occur in July) 05/01/2025 Accepted
6400.181(f)REPEAT 03/26/24- Individual # 1 had an assessment completed on 02/29/24. The ISP meeting was held on 03/22/24. Assessments must be provided to team members at least 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program specialist will receive retraining on the regulation to ensure understanding that assessments must be sent 30 days prior to ISP meeting date. 05/01/2025 Accepted
SIN-00220658 Renewal 03/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The temperature measures in the bathroom at the time of the inspection was 122.9 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. Maintenance was contacted immediately on 3/15/2023 and the hot water temperature setting was reduced to 115 degrees that day. 2. New water temperature thermometers will be ordered for each residential site by 4/11/2023 3. All other residential sites will have hot water temperature settings reduced to 115 degrees by 4/14/2023. 04/14/2023 Implemented
SIN-00184938 Renewal 03/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Rights- 11/18/2020- The rights that were reviewed with Individuals #1, #2 & #3 did not contain all of the new updated rights such as An individual has the right to choose persons with whom to share a bedroom, An individual has the right to access food at any time.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.FSI Individual Consents/Rights were updated on 3/18/2021. On 3/18/21 and 3/22/2021, all ID Management was trained on the updates to the form. Training of the updates will be completed by staff at all sites by 4/16/2021. The updated Individual Consent/Rights will be reviewed with and signed by individuals and mailed out for guardians review and signatures by 4/16/2021. 04/16/2021 Implemented
SIN-00149783 Renewal 02/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff # 1 received CPR/First Aid training on 7/8/16 and not again since.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. 1. Staff in question was recertified in CPR/First Aid/AED on 3/21/19. 2. As of 2/20/19, Family Services now has 2 CPR/First Aid/AED Trainers as there was previously only 1. 3. CPR classes are scheduled for 3/28/19, 4/4/19, 4/9/19 and 4/25/19 to be sure all staff are current in their certifications. 4. A new Training and Compliance Officer has been hired with a start date of 3/25/19. 5. Once initial training is completed, the Training and Compliance Officer will monitor the CPR certification dates of all ID staff and schedule trainings with the two CPR Instructors. 03/21/2019 Implemented
6400.186(a)The ISP review covering the period of 5/31/18 to 11/30/18 was completed late. It was completed on 1/23/19; the ISP review covering the period of 6/1/18 to 9/30/18 was completed late. It was completed on 11/6/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. 1. All Program Specialists were retrained on due dates and grace periods of ISP reviews (or quarterly reports) on 3/7/19. 2. As of 1/1/19, all ISP reviews are to be completed in monthly form and within 15 days of the end of month as per the ISP date. This keeps the entire team up to date on an individual¿s progress and needs. 3. All documents, including ISP reviews, Assessments, Track Changes to the ISPs as per 6400, 6500 and 2380 regulations will be up to date by 6/30/19. 4. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner. 5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information. 6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. 06/30/2019 Implemented
6400.213(11)The current ISP documents (in the physical assessment section) that Individual #1 needs to have eight 8 oz. glasses of water each day. The lifetime medical history (with the current assessment) also documents this same information. Upon discussion with staff, and review of medical documentation, it was determined that this individual does not have or need a protocol for liquid intake. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. 1. Track changes to the ISP were sent on 2/11/19 to update the liquid intake recommendation as it is no longer necessary. 2. All program specialists were retrained on 3/7/19 on updating the ISP whenever there are necessary changes in medical supports, physical decline, medication changes, protocols, etc. 3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner. 4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 12pm to complete trainings, review issues with individuals and/or staff, licensing or other information. 5. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17. 02/11/2019 Implemented
SIN-00076849 Renewal 05/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for this home was completed 4/15/15. Their licensing experiation is 6/30 and it should be completed 3-6 months prior to that date. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The Program Director is responsible for correcting the problem. There is no fix to the immediate problem. In response to the violation of 55 PA Code Chapter 6400.15(a) on June 30, 2015 all Program Specialists were retrained on the requirements of this chapter, including the need to complete all self assessments of each home the agency operates 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance. Family Services strives to create ongoing compliance, and completes regular and ongoing checks for compliance by using the self assessment tool. In the future, all official self-assessments will be completed within the designated time frames. Program Director, upon receipt of the licenses, will inform all Program Specialists of the need to complete the self-assessment, and the due date for those. See documentation of training (North 6th Avenue Attachment #2) In order to prevent future occurrence, all Program Specialists were re-trained on completion of self assessments. There is no document available for proof of ongoing compliance due to no self assessments needing completed until next year, 2016. 06/30/2015 Implemented
6400.46(i)Staff #2 did not have CPR/First Aide within annual time frame. It was completed on 11/3/2011 and then again on 7/21/2014. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. The Director of Training and Compliance is responsible for correcting the problem. There is no fix to the immediate problem due to it being in the past, and the current certification being up to date. In order to correct the potential for violation: 1. Since the violation occurred in July of 2014, a new system has been put in place in regard to tracking staff CPR/First Aid Dates. All dates are tracked via an excel spreadsheet with current certification dates as well as expiration dates of certification. (North 6th Avenue Attachment #4) 2. All staff files and certification dates were checked by office assistant to determine if they were up to date and were as of May 30, 2015. Upon discovery of non compliance of 55 PA Chapter 6400.46(i) In order to prevent future occurrence, the tracking sheet was implemented as of August 1, 2014. All staff are tracked using this system. In order to show ongoing compliance attached are several staff previous and current CPR/First Aid certifications (North 6th Avenue Attachment #5). 05/30/2015 Implemented
6400.112(c)The fire drill logs for June 2014 and July 2014 did not indicate if alarms are operativeA written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Program Specialist is responsible for correcting the problem. In order to correct the immediate problem: 1. Staff were retrained on June 4, 2015 on completion of a fire drill log, and requirements of fire drill logs. See training documentation (North 6th Avenue Attachment #1) Upon discovery of non compliance of 55 PA Chapter 6400.112(c) in addition to the fix to the immediate problem in order to prevent future occurrence, staff retraining occurred and Program Specialist will review all Fire Drill logs when they are turned in after completion (Program Specialist will initial and date the bottom of the fire drill log to show that it has been reviewed). Any fire drill logs that are done incorrectly will be returned to the house and corrections will be made. This expectation was reviewed with Program Specialists on June 30, 2015 and implemented immediately. (North 6th Avenue Attachment #2) To show ongoing compliance, fire drill logs from May 2015 and June 2015 are attached for review (North 6th Avenue Attachment #3) 07/01/2015 Implemented
SIN-00048639 Renewal 05/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(i)There is no progress and growth in sections (i) thru (ix) in the current assessment for Individual #1.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health. Program Specialists have reviewed the requirements for progress and growth necessary in the annual assessments. See attachment #3 A new checklist to ensure that areas of progress and growth are addressed during each assessment has been implemented. See attachment #2. The assessment for Individual #1 has been revised and updated as a example of future assessments. See attachment #1 Partially implemented / adequate progress. 06/05/2013 Implemented
SIN-00167856 Renewal 02/25/2020 Compliant - Finalized
SIN-00128616 Renewal 02/13/2018 Compliant - Finalized
SIN-00104671 Renewal 12/19/2016 Compliant - Finalized