Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288741 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 individual scores were absent from the initial training. While four observations were indicated as passing, they all occurred on 4/24/20. Additionally, it could not be established which were for the MAR as there were completed records for it. Two complete practicums for 4/14/25 and 12/27/25 existed. This does not fulfill the medication administration (re)training requirement.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 Retook initial medication training course in 2021, 2 on-site observations 3/20/2021. 06/12/2026 Not Implemented
SIN-00210938 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The Blinds were damaged in Individual 3's bedroom. The top right dresser drawer in Individual 3's room was missing a knob handle. The light at the base of the stairwell to the second floor near the kitchen was not functioning. The countertops in the kitchen were chipped and peeling around the edges of the countertop. Parts of the kitchen counter corners were taped with foil tape. The office desk was damaged with a hole on the top of the desk. There was a hole in the wall at the end of the hallway on the first floor. The main level bathroom shower was not functional, the floor was removed.Floors, walls, ceilings and other surfaces shall be in good repair. Blinds in all three bedrooms were replaced by Delta maintenance on 9/23/2022 (Attachment #9). Knobs on the dresser were replaced by Delta maintenance on 9/23/2022 (Attachment #10). The light at the base of the stairs was repaired with a new lightbulb by Delta maintenance on 9/23/2022 (Attachment #11). New countertops were installed on 9/15/2022 (Attachment #12). A new desk and new chairs were purchased on 8/31/2022 and placed in the home same day (Attachment #13). The hole in the wall at the end of the hallway on the first floor was repaired 9/6/2022 (Attachment #14). Delta maintenance has contracted with McBrick construction to complete all repairs on the bathroom (Attachment #15). 09/23/2022 Implemented
6400.80(b)The Gutters in the front of the home were clogged with leaves and debris from trees. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Gutters were cleaned by Delta maintenance on 9/17/2022 (Attachment #16). 09/17/2022 Implemented
6400.81(k)(2)Individual 1 and 2's mattresses were not in good repair. The mattresses had a sunk appearance and were not supportive. New mattresses have been ordered and purchased as of 8/31/2022, after the 8/29/2022 physical site review.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Mattresses were purchased and replaced on 8/31/2022 (Attachment #17). 08/31/2022 Implemented
6400.81(k)(3)Individual 3's bed did not have bedding. The bed was missing sheets, blankets and pillowsIn bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.Bedding was put back on the bed by residential coordinator on 8/29/2022 (Attachment #18). Individual removes the bedding and prefers not to sleep with sheets and blankets on the bed. Individual¿s support coordinator will be contacted by associate director to add this information to the ISP. 08/29/2022 Implemented
6400.82(f)The upper level bathroom was missing hand or paper towels and toilet paper. The main level bathroom was missing hand or paper towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Residential coordinator placed paper towels in the bathroom 8/29/2022 (Attachment #19). 08/29/2022 Implemented
6400.144Advil, take 1 tablet twice a day as needed, prescribed to Individual 2, was not available on site at the time of physical site review. The medication could not be given if needed, and it was not discontinued according to the medication administration record as of 8/29/2022.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The PRN Advil was reordered on 8/31/2022 by regional director (Attachment #20). Residential coordinator was contacted by the pharmacy via phone call that an updated script was needed which the residential coordinator obtained and sent to Tarrytown Pharmacy on 9/6/2022 (Attachment #21a). Residential coordinator was again contact via phone by Tarrytown Pharmacy to inform him that the prescription sent did not include the required information. Residential coordinator called the doctor¿s office again and asked for an updated prescription, which was sent directly to Tarrytown Pharmacy electronically. Residential coordinator obtained a copy of the electronic order on 9/26/2022 (Attachment #21b). 09/06/2022 Implemented
6400.32(r)Individuals 2 and 3's bedrooms did not have doors with the ability to lock.An individual has the right to lock the individual's bedroom door.The individuals and guardians for the residents in this home were contacted by the residential coordinator on 9/23/2022 and all stated they do not want locking doorknobs on the bedroom doors. This communication has been shared with the support coordinators to include in the individuals¿ ISPs (Attachment #22). 09/23/2022 Implemented
SIN-00187739 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Armorall cleaner was stored in lower kitchen cabinet during time of inspection and cabinet was not locked. It was removed at time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. The item was removed from under the sink at the time of the inspection. 05/27/2021 Implemented
SIN-00091519 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff # 10's annual fire safety training dated 10/20/2015 was not conducted by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Residential managers , Program Coordinators and Associate Directors participated in an annual fire safety train the trainer session on 10/14/16 Attachment # 16 completed by a fire safety expert Attachment # 17. Managers will participate in this training on an annual basis . Going forward, those managers trained as fire safety experts will complete face to face training for all staff at the homes where they work on an annual basis using the training materials provided by the fire expert Attachment # 18. . Any managers who were not in attendance will be trained by a fire safety expert by 11/30/16. Our trainer who was trained as a fire safety expert will train all new hires. 11/30/2016 Implemented
6400.64(a)There were multiple stains consistent with grease on the oven located in the kitchen.Clean and sanitary conditions shall be maintained in the home. Oven was cleaned on 5/13/16. Attachment # 25. Licensing concerns noted at 1 Spring Valley Road were addressed with the Residential Manager Attachment # 21 and the Program Coordinator Attachment # 22. Going forward Residential Managers will complete Residential Safety Checklists and complete work orders for any facilities concerns that are noted. Attachment # 13 . Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists Attachment # 14. Work orders will be completed for any facilities concerns noted. Attachment # 15. All management staff were trained on licensing requirements on 5/13/16 Attachment # 7. 05/13/2016 Implemented
6400.67(a)There was rust and dents on the dishwasher door located in the kitchen. There was a broken window on the shed located in the backyard.Floors, walls, ceilings and other surfaces shall be in good repair. Facilities replaced the dishwasher on 5/18/16 Attachment # 23 . Facilities fixed broken window on 5/18/16. Attachment # 24 . Licensing concerns noted at 1 Spring Valley Road were addressed with the Residential Manager Attachment # 21 and the Program Coordinator Attachment # 22. Going forward Residential Managers will complete Residential Safety Checklists and complete work orders for any facilities concerns that are noted. Attachment # 13. Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists Attachment #15. Work orders will be completed for any facilities concerns noted. Attachment # 15. All management staff were trained on licensing requirements on 5/13/16 Attachment # 7. 05/18/2016 Implemented
6400.77(b)The first aid kit did not have a thermometer 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. A thermometer was placed in the first aid kit on 5/12/16. Attachment # 20 . Licensing concerns noted at 1 Spring Valley Road were addressed with the Residential Manager Attachment # 21 and the Program Coordinator Attachment # 22. Going forward Residential Managers will complete Residential Safety Checklists and ensure that the first aid kit contains all required components. Attachment # 13 . Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists and ensure that the first aid kit contains all required components Attachment # 14. All management staff were trained in licensing requirements on 5/13/16 Attachment # 7. 05/13/2016 Implemented
6400.168(a)Staff # 44's initial practicum observer training dated 07/08/2014 is invalid as the observations were incomplete. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1 . All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
6400.168(d)Staff # 8's annual medication administration training dated 02/01/2015 was invalid as the first MAR review was completed on 03/08/2015, the second MAR review was completed on 06/14/2015, the third MAR review was completed on 09/10/2015 and the fourth MAR review was completed on 12/12/2015 Staff # 9's annual medication administration training dated 11/09/2015 was invalid as the fourth MAR review was not completed. Staff # 10's annual medication administration training dated 01/14/2015 was invalid as the first MAR review was completed on 03/08/2015, the second MAR review was completed on 06/14/2015, the third MAR review was completed on 09/10/2015 and fourth MAR review was completed on 12/12/2015. Staff # 11's annual medication administration training dated 10/12/2015 was invalid as the fourth MAR review was completed on 12/12/2015. Staff # 8's practicum observer training dated 07/20/2015 is invalid as there were no observations completed. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
SIN-00063889 Unannounced Monitoring 05/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 did not have an up to date financial record. Funds totaling $22.16 were missing.. Individual #2 did not have an up to date financial record. Funds totaling $29.76 were missing. Individual #3 did not have an up to date financial record. Funds totaling $12.45 were missing. Individual #4 did not have an up to date financial record. Funds totaling $54.93 were missing. (2) Disbursements made to or for the individual. Individual #1 was reimbursed $22.64 on 5/14/14. Individual #2 was reimbursed $29.76 on 5/14/14.1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached.2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached.3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. Individual #3 was reimbursed $12.40 on 5/14/14. Individual #4 the family was reimbursed $54.93 on 4/28/14 06/06/2014 Implemented
6400.22(e)(3)Individual #1 was missing receipts for $22.16. Individual #2 was missing receipts for $29.76. Individual #4 was missing receipts for $54.93 If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Increase training and management review of monthly ledgers. Reviewed financial procedures. Error made by staff with performance issues and job abandonment. Management will review receipts and ledgers on a weekly basis. 1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached.2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached.3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. 06/06/2014 Implemented
SIN-00047527 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.14(a)The home does not have a valid fire safety occupancy permit. The home has a licensed capacity of 6 and one person required physical assistance to evacuate the home on 3/20/12, 6/13/12, 8/8/12, 9/8/12, 10/17/12, 11/28/12, 12/27/12, 1/25/13, 2/22/13 and 3/19/13. (a) If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh, the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: Recordswe were able to locate and obtain copies of C1 Certificate of Occupancy issued 9/6/1994. Scanned documents will be forwarded via email. 04/30/2013 Implemented
6400.104Written notification letter to the fire department dated 1/28/13 does not identify that Individual #1 requires physicial assistance to evacuate the home.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. Letter sent to local fire department 3/27/13. Director will ensure that notifications remain current. 04/22/2013 Implemented
6400.141(c)(9)Individual #1 had a prostate examination on 2/13/12 and his next scheduled appointment was not completed until 3/21/13.(9) A prostate examination for men 40 years of age or older. medical appointment will be completed on a timely basis. Medical tracking is monitored utilizing Evolv and part of agency Balanced Score Card (QMP). PD will meet with medical records supervisor on a monthly basis. 04/22/2013 Implemented
6400.141(c)(12)Individual #1 requires physical assistance to evacuate the home during a fire drill. There were no physical limitations included on physicial examination completed 6/14/12.(12) Physical limitations of the individual. Phyisical limitations added to the current physical and signed off by Dr. on 4/18/2013 04/18/2013 Implemented
6400.142(e)Individual #1 was seen by a dentist on 4/10/12. He was required to complete a follow-up appointment within six months. The follow-up appointment was completed on 2/26/13.(e) Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.medical appointment will be completed on a timely basis. Medical tracking is monitored utilizing Evolv and part of agency Balanced Score Card (QMP). PD will meet with medical records supervisor on a monthly basis. 04/22/2013 Implemented
6400.186(c)(3)Individual #1 monthly ISP reviews for 10/12 thru 2/13 showed no progress was noted and modification to revise outcome was not recommendated to the Support Corrdinator.(3) The program specialist shall document a change in the individual's needs, if applicable.team meeting scheduled for 4/24/13 to discuss his change in needs and deteremine if updates need to be made to assessment and or ISP. PD will ensure that changes in needs are reflected in assessements and communicated to Supports Coordinator in a tiemly fashion. 04/24/2013 Implemented
6400.188(c)There was no programs, strategies or procedures to implement or track ISP outcomes for individual #1 outcomes which started 10/22/12.(c) The residential home shall provide services to the individual as specified in the individual's ISP. Outcomes were updated and new criteria was impletmented 4/3/2013. Will review with Supports Coordinator at team meeting on 4/24/13 04/03/2013 Implemented
6400.192The agency Restrictive Procedure policy did not include a process for the individual or the individuals family to review the use of the restrictive procedure.A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home. revision completed 3/28/13 adding that the individual and family will be informed. 03/28/2013 Implemented