Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243023 Renewal 04/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(c)It could not be determined as there is no written record nor a list if individual#1 attended fire safety training. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.The training will be completed by 6/3/2024 by the fire safety trainer and documented on the fire safety training form and will include all the participants and reviewed by the Program Director. 06/03/2024 Implemented
6400.52(c)(1)The annual training for staff member #1 did not include the subsections relating to ODP training around supporting individuals to maintain an everyday life.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Everyday lives training has been reassigned to staff #1 to be taken over and will be completed by 6/3/2024. 06/03/2024 Implemented
SIN-00224033 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The garage door was able to open but staff at the time of inspection was unable to close the door. Maintenance was called during inspection to repair it. Screens, windows and doors shall be in good repair. Facilities were called immediately when this occurred and came out and fixed the issue the same day. It¿s essential that all screens, windows and doors, to include the garage door are in good condition. 05/01/2023 Implemented
6400.77(b)There was no thermometer in the first aid kit. 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 full first aid kit is essential and must be on site to ensure the health and safety of individuals in the home. While there was a first aid kit, items were missing. Immediately after inspection a thermometer was purchased and added to the kit. 05/01/2023 Implemented
6400.106Documentation that a furnace inspections was completed annually was not provided.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. To ensure health and safety these inspections need to be completed annually. This inspection had been completed annually; however, we did not have the report available upon inspection. 05/01/2023 Implemented
6400.141(c)(10)Individual 1's Physical completed on 4/19/22 did not indicate if they were free from communicable diseases. Provider updated during inspection.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the PCP¿s office to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.141(c)(12)Individual 1's Physical completed on 4/19/22 did not indicate if they had physical limitations. Provider updated during inspection.The physical examination shall include: Physical limitations of the individual. While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the doctor¿s to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.141(c)(13)Individual 1's Physical completed on 4/19/22 did not indicate if they were any allergies. Provider updated during inspection.The physical examination shall include: Allergies or contraindicated medications.While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the doctor¿s to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.141(c)(14)Individual 1's Physical completed on 4/19/22 did not indicate if they were any medical information pertinent to diagnoses. Provider updated during inspection.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the doctor¿s to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.141(c)(15)Individual 1's Physical completed on 4/19/22 did not indicate if they were special instructions for their diet. Provider updated during inspection.The physical examination shall include:Special instructions for the individual's diet. While a physical was completed timely, information that is important and required by regulation was not obtained and reviewed by the physician. Immediately after inspection, our nurse went to the doctor¿s to address the areas that were not previously signed off or noted by the physician. 05/01/2023 Implemented
6400.163(d)There were two packs of Motrin found in the first aid kit which was being stored on top of the refrigerator in an unlocked container.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.the provider immediately threw out the motrin during inspection since it was not labeled by the pharmacy or prescribed. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors 05/01/2023 Implemented
SIN-00203984 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)For individual #1 there were incomplete records kept of her finances in the following months: -September 2021 ends with a balance of $0 -There are no cash on hand records for October, November or December 2021 - January 2022 starts with a balance of $81.72 -There is no record of February 2022 - March 2022 begins with a balance of $3.78 If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. There is a scheduled Clients funds retraining on 5/18/22 for all Team members handling client funds. We were able to attach and located the January-March 2022 ledgers, however we are doing a full audit and re-training on the 18th to track where the errors in Oct-Dec occurred. 05/18/2022 Implemented
6400.104There is not documentation that the notifications to the fire department were sent at the beginning of the current occupancy of 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. This was in place, however the notifications were not dated, so it was unclear as to when they were sent out to the fire departments. The letters were revised and sent out immediately after licensing to include the current date. 05/04/2022 Implemented
6400.112(e)The fire drills for 8 Beechwood Lane location did not have an overnight fire drill from 8/3/21 and 3/6/22A fire drill shall be held during sleeping hours at least every 6 months. Manager reviewed the 6400 regulations regarding Fire drills specifically overnight drills. The manager is new to 6400 regulations and received training, in addition an overnight fire drill was run. 05/04/2022 Implemented
6400.141(c)(14)The section referencing information pertinent to diagnosis and treatment in case of an emergency was not complete annual physical exam dated 11/8/21 for individual #1.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The individual has an upcoming physical appointment on 5/27/22, and this will be reviewed to ensure it is documented properly on the physical. In addition, the management team is meeting on 5/13/22 to review how documentation should look prior to any medical appointment and what the physician should complete on the required paperwork. 05/13/2022 Implemented
6400.144Individual #1 had a dental appointment on 1/22/22 which states that she needs periodontal work or her health will suffer. Similarly a casenote from 7/7/21 states that her teeth need to be extracted asap. Individual #1 is in need of a follow up appointment per the doctors requests.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. This dentist will not complete any procedures without the sign off and consent of the next of kin or guardian. The Program Specialist reached out to the individual¿s next of kin via phone and email. Received an email that the consent would be completed by sister, AP. Once received Merakey will schedule the appointment to complete the essential ordered work. 05/13/2022 Implemented
6400.216(a)Books with personal medical information on the individuals were stored unlocked in the dining room. An individual's records shall be kept locked when unattended. Medical records were immediately placed in a locked closet. 05/13/2022 Implemented
6400.52(c)(2)Staff #1 did not receive training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse during the 2021 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff #1 has completed training since citation. 05/04/2022 Implemented
6400.52(c)(3)There was no documentation showing that Staff #1 received training on individual rights during the 2021 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 has completed training since citation. 05/04/2022 Implemented
6400.163(d)There was a box of anti-diarrheal medication in the hall linen closet.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The anti-diarrheal medication was discarded immediately. This was not an individual¿s medication. 05/04/2022 Implemented
6400.181(f)Individual #1's Individual Assessment was not sent to the to the individual's Plan Team members by the program specialist at least 30 calendar days prior to an individual plan meeting, which took place on 12/07/2021. Documentation within the Individual Record indicates that the Individual Assessment was not sent to Individual Plan Team members until 12/16/2021.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 send Assessment 30 days prior to the Annual Review meeting. Unfortunately, and in this case, supports coordinators give us so little time to prep for the ISP that we do not have the option to send 30 days in advance. 05/04/2022 Implemented
SIN-00187188 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual 1 did not have an annual gynecological OBGYN exam. The most recent exam provided was dated 1/22/2020. More than one year has lapsed. Attempts to schedule appointment in 2021 calendar year was not provided at inspection.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual 1 had a lapse in her appointments due to Covid. It has been very challenging to schedule in person appointments for many individuals and we are trying to get everyone in as soon as offices are willing to see them and have availability. The wait lists are much longer than what we experienced pre-covid. Merakey recognizes the importance in ensuring all healthcare needs are addressed timely and will continue to do their best to ensure compliance. 06/23/2021 Implemented
6400.144Individual 1 did not have an annual dental exam completed annually, the last documented exam was dated 2/5/2020. Exam stated dental treatment was needed "ASAP". Follow ups made as soon as possible and correspondences were not received showing attempts throughout 2020 to presentHealth 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. Individual 1 had a lapse in her dental appointments due to Covid. The dental follow up was scheduled for March 2020 and was cancelled due to the shutdown that occurred. We made multiple attempts during the summer and fall of 2020, to get an appointment and were unsuccessful as the office was only seeing emergencies. It has been very challenging to schedule in person appointments for many individuals and we are trying to get everyone in as soon as offices are willing to see them and have availability. The wait lists are much longer than what we experienced pre-covid. Merakey recognizes the importance in ensuring all healthcare needs are addressed timely and will continue to do our best to ensure compliance. 07/07/2021 Implemented
SIN-00115291 Renewal 05/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed on 5/10/2017 and the license expired on 2/01/2017.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 agency should complete a self assessment of each home within 3-6 months prior to the expiration date of the agency's certificate of compliance. The assessment was completed 3 months after the license expired. The provider will continue to strive to meet this necessary requirement. [Going forward, a Program Designee will monitor to ensure compliance with meeting the required deadline. JG 11/28/17]. 05/10/2017 Implemented
6400.71There were no emergency telephone numbers posted in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. There were no emergency telephone numbers posted in the home. Telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center were posted on or near the house phone with an outside line. 09/05/2017 Implemented
6400.141(a)The current annual physical examination for Individual #1 occurred on 10/20/2016; the date of the previous physical is 10/02/2015.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The medical book review showed a lapse in physical of just over the 2 week grace period. The provider made every attempt to have the annual physical completed within the required period however the doctor's office could not accommodate this need. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individual's served. [Going forward, a Program Designee will monitor to ensure compliance with meeting the required deadline and ensure that MEDICAL APPOINTMENTS ARE SCHEDULED WELL IN ADVANCE OF WHEN DUE TO ENSURE THAT THE APPOINTMENTS OCCUR PRIOR TO END OF THE GRACE PERIOD. JG 11/28/17]. 09/05/2017 Implemented
6400.141(c)(3)Individual #1's most recent Tetanus Diptheria immunization was received on 3/09/2007.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The medical book reviewed was lacking a current Immunization regarding the Tetanus Diphtheria. All individuals 18 years of age or older should have a list of immunizations included in their yearly physical. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits are completed of our medical books to ensure compliance in this area and a follow up appointment was made to ensure that the individual received the required immunization. 09/05/2017 Implemented
6400.141(c)(8)Individual #1's most recent mammogram occurred on 1/04/2017; the previous mammogram was dated 7/20/2015.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The medical book reviewed showed a mammogram that was done on 1/4/17. No annual mammogram was done for 2016. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits will be completed of our medical books to ensure compliance in this area. 01/04/2017 Implemented
6400.163(c)Individual #1 had a psychiatric medication review on 6/23/2016; the date of the next psychiatric medication review was 10/03/2016. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.It is essential that individuals who receive psychiatric care receive a medication review every 90 days or more frequently if needed. As a result of a cancellation with the doctor's office, there was a lapse in psychiatric care. Please see attachment to note that this is currently being followed up on and addressed to ensure compliance. [Going forward, a Program Designee will monitor to ensure compliance with meeting the required deadlines. JG 11/28/17]. 09/05/2017 Implemented
6400.186(a)Individual #1's quarterly review of the ISP covering the period of 8/23/2016 to 11/22/2016 was not completed until 12/23/2016.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. The program specialist must complete quarterly ISP reviews of the services and outcomes every 3 months or more frequently. There should not be a lapse in completion of the ISP reviews, of more than 2 weeks at the end of the quarter. The provider incorrectly completed an ISP review over a month after the quarter was complete. To ensure that documentation is relevant, current and outcomes are accurately followed, completing ISP reviews in a timely manner is essential. Please see attached most recent ISP review and accurate dates of completion. [Going forward, a Program Designee will monitor to ensure compliance with meeting the required deadlines. JG 11/28/17]. 09/05/2017 Implemented
SIN-00095006 Renewal 02/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The entertaiment center located in the living room had a missing right door. Furniture and equipment shall be nonhazardous, clean and sturdy. This has been corrected. The entertainment center was disposed of. Furniture must be in good and safe condition. Lashawn Ford, manager of the home submitted a request to facilities asking that this item be removed from the home. All other homes were checked for furniture during site inspection and no other items were found to be in poor condition.[Home Manager or Program designee will complete monthly checks of all homes to ensure that all furniture and equipment is nonhazardous, clean and sturdy. If any furniture or equipment is found to not meet the regulations, maintenance will be notified to repair or remove the furniture. Quality Manager or program Designee will quarterly audit the checks to ensure compliance. These steps will be implemented within 30 days of receipt of this plan of correction dd 6.10.16] 02/05/2016 Implemented
SIN-00069716 Renewal 10/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Individual # 1's bedroom dresser is missing 7 knobs. Furniture and equipment shall be nonhazardous, clean and sturdy. All furniture must be clean and sturdy. The bedroom dresser for individual 1 at this location had the handles replaced. A monthly check of all furniture and equipment will be conducted by the Program Specialist and issue a work order immediately to facilitate any necessary repairs. 10/15/2014 Implemented
SIN-00264588 Renewal 04/17/2025 Compliant - Finalized
SIN-00161356 Renewal 08/13/2019 Compliant - Finalized
SIN-00142666 Renewal 06/18/2018 Compliant - Finalized
SIN-00042166 Renewal 10/10/2012 Compliant - Finalized
SIN-00043262 Renewal 10/10/2012 Compliant - Finalized