Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00091520 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was dirt and grease on the top of the refrigator located in the kitchen.Clean and sanitary conditions shall be maintained in the home. The top of the refrigerator was cleaned on 5/9/16. Attachment # 27. Going forward Residential Managers will complete Residential Safety Checklists and will ensure that any areas of the home identified will be cleaned immediately. Attachment # 13. Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists and ensure that any areas of the home identified will be cleaned immediately. Attachment #14. All management staff were trained on licensing requirements on 5/13/16 Attachment # 7. 05/13/2016 Implemented
6400.72(b)There was a torn screen in the window located in the kitchen Screens, windows and doors shall be in good repair. Facilities replaced the torn screen on 5/13/16. Attachment # 26. 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
6400.168(d)Staff # 22's annual medication administration training dated 10/25/2015 was invalid as the fourth MAR review was completed on 12/03/2015.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. Implemented
SIN-00075974 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 #1's, hired on 1/26/15, criminal history check was completed on 1/27/15. Staff #5's, hired on 10/20/14, criminal history check was completed on 10/28/14. 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. 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. 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. 03/02/2015 Implemented
SIN-00245946 Unannounced Monitoring 05/30/2024 Compliant - Finalized