Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261931 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)In the records of individual #4, a Receipt for 23.33 was not filed for transaction at dollar tree on December 17, 2024. 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. All staff at Individual #4¿s home will be retrained in the proper documentation of purchases for individuals exceeding $15 by 4/4/2028. Staff will use a sign in/sign out sheet for the PEX card to document (attachment 5a) when the PEX card leaves the house and to document any purchases that were made at that time. 03/28/2025 Implemented
6400.82(d)The main bathroom did not have any window covering.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. A maintenance order was submitted on 3/4/2025. Maintenance spray frosted the window on 3/5/2025 creating a privacy covering in the bathroom. See attachment 5b 03/05/2025 Implemented
6400.144Individual #4 had a Neurology appointment on 6/18/24. At this appointment a follow up was requested in November 2024, however there is no documentation that this follow up occurred.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 medical coordinator reached out to Individual #4¿s neurologist to reschedule her follow up appointment, which should have taken place in November 2024. The neurologist appointment was scheduled for April 16, 2025. See attachment 1 and 5c 03/28/2025 Implemented
SIN-00240604 Renewal 03/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Two of the bathrooms in the home had soap in unlabeled decorative containers.Poisonous materials shall be stored in their original, labeled containers. All poisonous materials will be stored in their original containers. The hand soap in the bathroom was removed and disposed of on 3/6/24 at the time of inspection by the house supervisor. the department has protocols for storing all poisonous materials. 03/21/2024 Implemented
6400.34(a)There is no documentation that Individual #1, Individual #2, Individual #3 and Individual #4 were informed of their right to lock their bedroom door and to have a key or other mechanism to gain entry to the door of their home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual #1, Individual #2, Individual #3, Individual #4 were informed of their right to lock their bedroom door and to have a key or other mechanism to gain entry to the door of their home utilizing the DEC Corporate Operations Policy No. Q1 - Residential rights by 4/6/24 by the Assistant Directors. 04/06/2024 Implemented
SIN-00182445 Renewal 02/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Ventilation fan in main bathroom was covered in dust and dirt.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions shall be maintained throughout the home. The main bathroom ventilation fan was observed to be covered in dust and dirt at the time of inspection. The bathroom vent has been cleaned. The Residential Director retrained all the house supervisors in the requirements listed under 6400.64a, including a review of the monthly house checklist on 3.24.2021. 04/15/2021 Implemented
6400.144Individual #1 medication Lysinoprail label states it is only to be taken when blood pressure falls within a certain range. On the dates of 1/2/21, 1/5/21, 1/6/21 and 1/20/21 either the blood pressure was not taken and/or recorded or the blood pressure was recorded and this medication was given when it should not have been given.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. 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. Individual #1 is prescribed Lisinopril with specific instructions of when it is to be administered. On 1/2/21, 1/5/21, 1/6/21, and 1/20/21 there was no documentation of her blood pressure readings, and this medication was administered when it should not have been. The medical coordinator has copies of the doctor's order for the Lisinopril that are kept in individual #1¿s central file. All residential supervisors were retrained by the Director in individual #1¿s blood pressure protocol. 04/15/2021 Implemented
6400.32(e)Thermostat in home was locked and the house staff nor the individuals had a key. When the individuals do not have immediate ability to have the temperature in their home increased or decreased, they are denied their right to make choices.An individual has the right to make choices and accept risks.An individual has the right to make choices and accept risks. The thermostat was observed to be covered by a locked case, without an available key to access it. The Maintenance Director placed a key inside the home on 3.1.2021; all individuals and staff have access to the thermostat at all times. 03/01/2021 Implemented
6400.165(g)It could not be determined if individual #1 received timely psychiatric medication reviews as the different dates appeared on the same form and the medication and dosages being reviewed were not indicated on the form.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.If a medication is prescribed to treat symptoms of psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. There was no documentation of a medication review on the psychiatric appointment forms for individual #1. The date of individual #1's medication review was not clearly identified on the form. The Program Specialist was retrained by the Director on 3/24/21 in the requirements for medication review appointments and all the paperwork that is required. 03/24/2021 Implemented
6400.181(f)No documentation was available at the time of inspection to verify that individual #1 assessment was mailed to the plan team prior to the 5/2020 individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. There was no documentation supporting that the assessment for Individual #1 was sent to the team prior to the 5/2020 meeting. The Program Specialist will be responsible for sending the assessment out 30 days prior to the ISP meeting. The Program Specialist was retrained by the Director on 3.24.2021 on the plan of correction as it relates to the requirements for assessments. 03/24/2021 Implemented
SIN-00130366 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The furnace room floor needs cleaning and debris removed.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions shall be maintained in the home. The furnace room was cleaned and debris was removed on 1/30/18; the room will be monitored for ongoing cleanliness as part of the site safety inspection. The house supervisor is responsible for the site inspection with oversight from the Assistant CRD Director. Staff will be retrained on site safety checklist completion and site inspections on 3/29/18. 01/30/2018 Implemented
6400.72(b)The office room has a torn screen door and does not properly close. Screens, windows and doors shall be in good repair. All screens, windows, and doors should be in good repair. The door was fixed on 2/26/18. All staff will be retrained on 3/29/18, on completing the site safety checklist and identifying hazards. 02/27/2018 Implemented
6400.112(h)The fire drill dated 1/16/17 did not indicate meeting place, or if an alarm was used or in working order. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. Staff were retrained on (2/1/18) in how to fill out the fire drill form appropriately. The report from the fire alarm company dated 1/16/17 indicated that the alarm was working. All staff will be retrained during annual fire safety training on 3/29/18. The CRD administrative assistant will review all fire drill documentation for completion. The director will review all fire drill documentation each month. 02/01/2018 Implemented
SIN-00107142 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were multiple dried liquid spit marks which varied in size found on the wall of Individual # 1's bedroom. Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home. This wall was cleaned on 2/28/2017 however the spots remain. Maintenance is in the process of repairing and repainting this bedroom. Staff will be retrained in the site safety checklist and their responsibility to ensure compliance by April 1 2017. Supervisors responsible to ensure safety checklist are submitted and correct. CRD Director or ACRD Director will complete unannounced house checks for cleanliness. Attachment # 11. 04/28/2017 Implemented
6400.67(a)There was peeling paint which varied in size found on the wall of Individual # 1's bedroom. Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings and other surfaces will be in good repair. Maintenance has begun to repair the wall and is expected to be completed by 4/20/2017. Additionally they will be putting cork board up for the individual to put pictures and stickers on as she puts them up and tears them down causing the paint to peel. Staff will be retrained in the site safety checklist and their responsibility to ensure compliance by April 1 2017. Supervisors responsible to ensure safety checklist are submitted and correct. CRD Director or ACRD Director will track accuracy. Attachment # 11 04/28/2017 Implemented
6400.112(d)The fire drill record dated 09/10/2016 documented an evacuation time of four minutes and eight seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Individuals will be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The individuals in question are able to evacuate in 2 1/2 minutes. This drill was completed when one of the individuals was sick and very slow with evacuation; also timed incorrectly. All fire drills since Sept 2016 were within the allotted time frame. See attached fire drills. The supervisor is to ensure drills are compliant and if not are to notify the CRD director within 24 hours as written on the fire drill form. Supervisor was retrained in this procedure. The Residential Coordinator and or the Administrative Assistant are responsible for reviewing each fire drill for compliance. Additionally fire safety is discussed monthly at house meetings. 02/28/2017 Implemented
SIN-00086988 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)Individual #1's physical dated 3/20/15 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. The physical examination will include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical coordinator will complete information prior to the examination for the doctor to sign off on the physical. Additional review of the physical form will be done by the medical coordinator. Addendum # 2. 01/29/2016 Implemented
6400.141(c)(14)Individual #1's physical dated 3/20/15 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination will include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical coordinator will complete information prior to the examination for the doctor to sign off on the physical. Additional review of the physical form will be done by the medical coordinator. Addendem # 2. 01/28/2016 Implemented
Article X.1007Developmental Enterprises Corporation 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 person #1 date of hire 8/6/15 indicated they did not live in Pennsylvania for the past 2 years, and did not have an FBI criminal check completed. 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.DEC procedure revised that all new employees will undergo a FBI criminal history check. Addendum #7 01/04/2016 Implemented
SIN-00049761 Renewal 07/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The home did not conduct fire drills during the months of July, 2012, October, 2012, November, 2012, and December 2012(a) An unannounced fire drill shall be held at least once a month. A random check on fire drills in January 2013. It was at this time we discovered some discrepancies which led to a full investigation. After the investigation, it was determined that fire drills were falsified and missing and the staff involved was terminated. Due to the time frame there was no way to go back and re-run fire drills to meet the regulation of having a fire drill on a monthly basis. While we cannot prevent falsification, we can closely monitor each drill in a timely manner so that any discrepancy is found within the same calendar month allowing for a valid drill to be run each month. Our plan of correction is as follows: 1. All staff was re-trained in fire drill specifics including filling out forms, necessity of accurate information and their signature indicates accuracy of the report. In addition to annual fire safety training in these specifics was done in April 2013 and will be done each year. 2. All fire drills submitted have and will continue to be verified by the administrative assistant by checking the alarm company report (protection one) online by the 28th of each month. If the information is inaccurate, the CRD Director will be notified and staff involved will be suspended pending the outcome of investigation. The Residential Coordinator will conduct another fire drill within 24 hours to ensure compliance. This has been in place since 1/28/2013 and all drills have been verified and documentation of verification was attached to each fire drill for review during annual inspection. 3. In the absence of the administrative assistance, the backup will be Residential Coordinator and in the absence of the CRD Director the Program Director will be notified of the discrepancy. 08/01/2013 Implemented
6400.112(f)The home conducted 10 fire drills between 7/12/12 and 6/13/13. The front door was used as the exit for all of these drills(f) Alternate exit routes shall be used during fire drills. A new schedule was developed and a plan put in place to ¿block¿ an exit by using a visual cue of cardboard flames to force alternative exits being used for fire escape routes. In July 2013 the sunroom exit was used as an exit which differs from the front door that was being used. Additionally, due to the physical limitations of the individuals, it was difficult for them to get to the designated meeting place when exiting the rear of the house therefore the front of the homes was being used consistently. We have now designated a second designated area when exiting from the rear of the home. All individuals and staff where trained in this new procedure on July 29, 2013. 08/01/2013 Implemented
SIN-00201394 Renewal 03/01/2022 Compliant - Finalized
SIN-00063499 Renewal 07/01/2014 Compliant - Finalized