Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00291789 Renewal 07/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 07/09/26, at 11:19 AM, there was not a smoke detector in the basement. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Smoke detector, strobe and horn were added to the basement of the home 7.14.26. 07/14/2026 Implemented
6400.151(a)Program Specialist #1, date of hire 02/23/26, had a physical examination completed on 02/24/26. This exceeds the requirement of the employee having the physical examination completed within 12 months prior to employment. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The Human Resources Director and Human Resources Specialist were trained on 7/30/2026 regarding the regulatory timelines of 55 Pa. Code § 6400.151(a), emphasizing that physicals must be completed prior to employment. The Human Resources Specialist completed an audit of all active residential staff's initial physical dates and compared them to their date of hire to check compliance throughout the department. Though the physical dates cannot be corrected, all non-compliances were recorded. 10/31/2026 Implemented
SIN-00192994 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 02/01/21 did not include indications of compliance or non-compliance for regulations 6400.111f-112h, 113a-114b, or 161a-167d1.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. Self Assessments will be reviewed by Residential Administrator once completed . Self Assessments will be completed Prior to 12/31/21 so that they can be thoroughly checked over. 12/31/2021 Implemented
SIN-00157699 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1, date of admission 07/28/18 had a initial physical examination completed 10/23/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. MCAR Residential Director will provide individuals with the MCAR physical form upon acceptance into the Residential program. After Residential Director receives the referral from SC, Residential Director will email a copy of the MCAR physical form to the SC for the individual to have completed before starting services. Once MCAR Residential Director receives the physical form it will be reviewed by Nursing Director and Residential Director to ensure all areas of the form are filled out entirely. Next the Residential Director will forward a copy to the case manager for the that individual. The case manager will schedule the annual physical for that individual and set reminders for annual physicals to be completed in there outlook calendar. An updated physical has been completed for this individual in question and supporting documentation will be email. [Individual #1 had a physical examination completed 10/23/2018. The physical examination is not completed with required information. Immediately, the CEO or designee shall follow up with the physician to ensure all required information is completed and Individual #1's health services are provided arranged. Immediately and upon competition of all individuals' current physical examination, a designated staff person who is educated in the requirements of Individual physical examination requirements and the agency's procedures for following up on physician's orders, shall audit all individuals' physical examinations to ensure all required areas are addressed and follow up completed to ensure all individuals' health needs are arranged and provided for. Documentation of audits, follow up arrangements and trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of all individuals physical examinations and the aforementioned tracking system to ensure all individual are completed timely with all required information and all individuals' health services are arranged and provided as required. (DPOC by AES,HSLS on 9/9/2019)] 07/11/2019 Implemented
SIN-00096251 Renewal 06/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)Twelve fire drills were held between 5/14/15 and 4/17/16. The back door was used as the exit route for eight out of the twelve fire drills.Alternate exit routes shall be used during fire drills. Staff will be retrained at In service training in September 2016, dates have yet to be identified. A Rolodex has been created for each home to ensure all exits used are alternating with the month. Residential Program Specialist will ensure that the alternate exits are used by initialing and dating the houses fire drill once received and reviewed..[Within 90 days of receipt of the plan of correction, the Administrator of Residential Services will develop and implement policy and procedures to ensure fire drills are unannounced and alternate exit routes are used during fire drill. Staff responsible for conducting fire drill and documenting and reviewing fire drill shall be trained in the policies and procedures. Documentation of reviews shall be kept. (AS 7/11/16)] 07/01/2016 Implemented
SIN-00080258 Renewal 06/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at the bathtub of the main bathroom measured 122.7 degrees Fahrenheit at 9:55 AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. A Memo was sent to all staff on 6/29/2015 on the importance of the water temperature in the group home not exceeding 120 degrees was sent to all group homes via email and paper copy. All staff will be retrained on water temperature information at the August 2015 in-services 8/7/2015, 8/12/2015, and 8/19/2015. Program Specialist will continue water temperature checks weekly at different locations of the home, this is logged on their weekly checklists. 07/02/2015 Implemented
SIN-00249281 Renewal 08/06/2024 Compliant - Finalized