Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247581 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment began and ended on 7/9/2024. The self-assessment was not completed within the proper timeframe.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. We did not recognize we have been misreading the regulations regarding the timing of when the self-assessment is to be conducted. To correct that, our self-assessments will occur between 2/23/25 and 5/23/25, as our license date is 8/23/25. 07/19/2024 Implemented
6400.68(b)The water temperature in the hallway bathroom was 125 degrees F during the physical site walk through. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance adjusted the water temperature to bring it into compliance. 09/10/2024 Implemented
6400.77(b)There was no tape in the first aid kit during the physical site walk through. 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. The missing tape was replaced. 09/10/2024 Implemented
6400.141(c)(9)Individual # 1 did not receive a Prostate Exam in the year 2023.The physical examination shall include: A prostate examination for men 40 years of age or older. This incident cannot be fixed from 2023. When this occurred, the Program Specialist at the time left 1 week after the physical, there was no permanent Supervisor at the program and other Supervisors were assisting. Despite this, it is not at all satisfactory. There is a permanent Supervisor at the program now, with oversight from a Program Specialist and recently a new Associate Director. 08/30/2024 Implemented
6400.143(a)Individual # 1 refused to cooperate during eye appointments on 12/05/22 and 12/05/23. There is no documentation that the agency attempted to train the individual about the need for health care. Additionally, Individual # 1 refused to get out of their chair to participate in a Neurology appointment on 04/23/24. There is no documentation that the agency attempted to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Create and review a Social Story with the individual to desensitize him to medical appointments. 10/05/2024 Implemented
6400.144(REPEAT 07/11/23)- Individual # 1 has a diagnosis of Constipation and saw a Gastroenterologist on 12/05/23 with a follow up appointment scheduled for 02/13/24. Individual # 1 did not receive a follow up appointment until 05/24/24.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. There is no immediate action to fix this. The appointment was rescheduled due to inclement weather as there was a snowfall event that day. (Below is link to weather that day) Snow has hit central Pa.: How much will fall and when will it stop - pennlive.com 09/10/2024 Implemented
6400.167(a)(3)Individual # 1 has a bowel protocol which requires the administration of Lactulose 10GM/15ML SOL should he/she not have a bowel movement for three days. Individual # 1 had a bowel movement on 06/06/24 at 9 am but was given a dose of Lactulose on 06/08/24 at 8pm in error and prior to the three day requirement for the Lactulose PRNMedication errors include the following: Administration of the wrong dose of medication.EIM # 9452166 entered. 10/08/2024 Implemented
6400.186Individual # 1 has a diagnosis of constipation and the ISP last updated on 06/06/24 indicates that staff are to prompt Individual # 1 to use the toilet every two hours while they are at home. The agency tracking form on 06/10/24 shows that staff completed BM reminder/check at 2pm and not again until 6 pm the spaces were left blank. Additionally, on 06/15/24 a check/reminder was completed at 8 am and not again until 4pm. The spaces in between those times were left blank.The home shall implement the individual plan, including revisions.On 8/15/24 at a joint Program Supervisor/Program Specialist there will be trainings on the forms and processes related to these POCs. 08/19/2024 Implemented
SIN-00235415 Unannounced Monitoring 11/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's was November 6th doctor's appointment recommended 1:1 staffing ratio at night for fall prevention. This was not put into practice until Nov 16th.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. As the issue involved the Program Specialist not acting upon a doctor's recommendation, on Thursday, December 15, 2023 all Program Specialists, Compliance Specialists and Associate Director were retrained on 6400.144, where it was reiterated what the expectation is to act upon and elevate recommendations from any health service practitioner. 12/15/2023 Implemented
SIN-00216114 Unannounced Monitoring 12/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The window blinds in individual #2's bathroom were broken and need to be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. Immediate POC - the blind was replaced 12/26/2022 Implemented
SIN-00107720 Renewal 04/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Repeat 4/5/16: The bathroom sink is chipping and has a brown stain approx 6" long in sink. Floors, walls, ceilings and other surfaces shall be in good repair. Bathroom sink and counter top were replaced on 4/28/17 by maintenance staff. The Property Manager did site reviews at all homes to check for surfaces in good repair. Any needed repairs were scheduled and addressed by our maintenance staff. 05/01/2017 Implemented
6400.141(c)(6)Individual #1 had a tuberculin test completed on 2/12/15 and not again. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. An appointment was made for a TB test for Individual #1 on 4/12/17 and the test was read on 4/14/17. (See submitted med appointment review). A memo was sent to Supervisors reminding them of this regulation, and all were required to complete a form verifying completion dates for TB tests. 04/28/2017 Implemented
6400.141(c)(8)Individual #1 had a mammogram completed on 3/17/15 and not again until 7/13/16.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. A memo was sent to all Supervisors reminding them of the need to assure that mammograms are scheduled at least every two years for women age 40 to 49, and at least every year for women 50 years of age and older. All Supervisors were required to complete a form verifying completion dates for mammograms for women in their programs. 04/28/2017 Implemented
6400.141(c)(14)Individual #1's physical dated 7/13/16 did not include info pertinent to diagnosis and treatment in case of emergency. It was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The medical information pertinent to diagnosis and treatment in case of an emergency was added to Individual #1¿s 7/13/17 physical. All current physicals were reviewed by Residential Supervisors to assure that this information is up to date on all individuals¿ physicals. A memo was sent to Supervisors reminding them of this regulation. 04/26/2017 Implemented
6400.181(e)(8)Individual #1's assessment completed 7/28/16 did not include his/her ability to evacuate in the event of a fire. The assessment must include the following information: The individual's ability to evacuate in the event of a fire. The Program Specialist wrote an addendum to Individual #1¿s 7/28/16 Assessment to include her ability to evacuate in the event of a fire, and this was sent to all team member on 4/21/17. Also a training was held for all Program Specialists reviewing all information necessary to be covered in Assessments on 4/27/17. 04/27/2017 Implemented
6400.183(5)Individual #1's ISP updated 12/21/16 did not include a protocol to address social, emotional, nviromental, needs plan. Individual #1 takes Seroquel XR 100mg 1 tab QD and Paxil HCL 40mg 1 tab QD and Paxil HCL 10mg 1 tab QD. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The Program Specialist wrote an addendum to Individual #1¿s ISP to include protocol to address a SEEN plan. A general update was sent to the SC on 4/21/17. Also a training was held on 4/27/17 for all Program Specialists to review this regulation and the information necessary for the ISP. 04/27/2017 Implemented
6400.186(c)(2)Individual #1's ISP reviews dated 4/28/16, 7/28/16, 10/27/16, and 1/27/17 did not include a review of bowel protocol which is tracked daily on a chart. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Individual #1had an appointment with her PCP on 4/12/17 and obtained clarification regarding her bowel protocol. (See submitted medical appointment review form and scripts). The Program Specialist wrote an addendum for the lifetime medical history and ISP to clarify the bowel protocol. The quarterly review for Individual #1 on 4/29/17 includes a review of the bowel protocol. 04/29/2017 Implemented
6400.186(c)(5)Individual #1's assessment completed on 7/28/16 states that his/her can be at home unsupervised for 1 hour however ISP updated 12/21/16 states that he/she can be unsupervised at home up to 2 hours. The assessment should have an addendumm for when the suupervision needs changed. If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment as required under § 6400.181(b) (relating to assessments). The Program Specialist wrote an addendum to Individual #1¿s Assessment (Safety in the Home, and Home Supervision sections) on 4/21/17 (See submitted documentation).Also an addendum to the ISP Fire Safety Section, and Supervision section on 4/21/17. A general update was sent to the SC also on 4/21/17 was written. 04/21/2017 Implemented
6400.186(d)Individual #1's ISP review dated 4/28/16, 7/28/16, and 1/27/17 were not sent to all team members. They were not sent to his/her brother. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. All current Accept/Decline forms for all individuals have been copied and are kept in our main office so the Program Specialist has easy access to assure that all interested individuals are mailed copies of ISP information. A training was held on 4/27/17 for all Program Specialists to review their responsibilities regarding ISP review and revisions. (See submitted documentation). 04/27/2017 Implemented
6400.186(e)Individual #1's ISP reviews did not include option to decline to his/her brother. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The Program Specialist contacted Individual #1¿s brother to determine his interest in receiving ISP¿s and reviews on 4/21/17. He declined receiving them, and this has been noted in her records. A training was held for Program Specialists reviewing the regulations regarding ISP review and revisions on 4/27/17. 04/27/2017 Implemented
SIN-00212882 Unannounced Monitoring 09/30/2022 Compliant - Finalized
SIN-00205303 Unannounced Monitoring 05/12/2022 Compliant - Finalized
SIN-00168446 Renewal 07/14/2020 Compliant - Finalized
SIN-00132135 Renewal 04/23/2018 Compliant - Finalized