Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288740 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 Practicum only had one MAR review and one observation on 3/28/25.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 6/1/2026 Staff #2 Retook initial medication training 5/30/2026, with on-site observations 5/31/2026 06/12/2026 Not Implemented
SIN-00244203 Renewal 05/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)In the basement, the top stair leading out of the Bilko doors was broken. Floors, walls, ceilings and other surfaces shall be free of hazards.The broken step was repaired by Maintenance technician on 5/23/2024. See attachments labeled 67b Woodside Step 1 & 67b Woodside Step 2. 05/23/2024 Implemented
SIN-00166427 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The Range Hood over the stove was not clean and sanitary.Clean and sanitary conditions shall be maintained in the home. The grease has been cleaned from the stove hood 10/1/19. A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.66There was no light in individual #2's bedroom.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light switch in Individual #2's room has been fixed 9/26/19. (Attachment #28) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.67(a)The kitchen cabinets were missing knobs.Floors, walls, ceilings and other surfaces shall be in good repair. The knob on the kitchen cabinet has been replaced 9/24/19. (Attachment #29) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.67(b)There was Lint build-up found in the dryer. The Inspector was unable to access the homes attic based on safety. The Ladder was not in good repair. Floors, walls, ceilings and other surfaces shall be free of hazards.The flexible hose on the dryer vent has been cleaned 10/22/19. (Attachment #30) The attic access has been moved to the kitchen on 10/11/19 (Attachment #31) A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. 02/01/2020 Implemented
6400.181(e)(14)Individual #1's assessments completed on 3/11/19 and 3/11/18 have inconsistencies. Under the likes section, it states individual #1 likes to swim, however under the water skills section it states he doesn't like to swim. Also, the Knowledge of water safety is not fully addressed in the assessment.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Assessment template redone on 10/1/19 to update and amend to include clear likes and water skills. (Attachment # 3) Individual # 1's assessment has been redone on the new template and sent to his team. (Attachment #32) Going forward all assessments will be completed on the new template by the Program Specialists. 12/10/2019 Implemented
SIN-00091515 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were three tubs of Great Valve powered laundry detergent which indicated to contact poison control if ingested, found unlocked in the laundy roomPoisonous materials shall be kept locked or made inaccessible to individuals.The laundry detergent had been removed from the laundry room and stored in a locked cabinet on 5/9/16. Attachment # 19. Going forward Residential Managers will complete Residential Safety Checklists to ensure any poisons are properly stored. Attachment # 13. Associate Directors will conduct monthly walkthroughs of the home and complete Compliance Checklists Attachment # 14 to ensure any poisons are properly stored. Any poisons discovered, will immediately be removed and placed in proper storage. All management staff were trained in licensing requirements on 5/13/16 Attachment # 7. 05/13/2016 Implemented
6400.168(a)Staff # 26's initial practicum observer training dated 11/15/2013 is invalid as the observation were incomplete. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. 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. 05/16/2016 Implemented
6400.168(d)Staff # 26's annual medication administration training dated 10/19/2015 was invalid as the fourth MAR review was completed on 12/08/2015. Staff # 27's annual medication administration training dated 11/04/2015 was invalid as the fourth MAR review was completed on 11/10/2015.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. 05/16/2016 Implemented