Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288738 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 and Staff #2's annual practicum was incomplete with only one observation and no 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).Staff #1 Termed on 3/31/2026 Staff #2 Files show Med Observations & MAR Reviews conducted on Sept & March 2025 06/12/2026 Not Implemented
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-00266380 Renewal 05/15/2025 Compliant - Finalized
SIN-00245946 Unannounced Monitoring 05/30/2024 Compliant - Finalized