Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00288742 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 last certification date was on10/29/19.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 Initial date was 10/30/2019. We have 2 Obs & MAR for 2025 (3/3/25 and 9/6/25) 06/12/2026 Not Implemented
SIN-00244209 Renewal 05/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(f)For individual 4's medication review: 100mg cough syrup medication was stored in the refrigerator and not in a locked box.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.The cough syrup for Individual 4 was removed from the refrigerator on 5/8/2024, as this medication did not require refrigeration, and it was placed in a locked box where the rest of the medications are stored. See attachment labeled 163f Endfield Medication Locked Area. 05/08/2024 Implemented
SIN-00210924 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual 1's ISP indicates cleaning materials are kept locked in the house. Poisonous materials were found in an unlocked cabinet beneath the hallway bathroom's sink, including Febreze spray and several bottles of hand sanitizer.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisons were locked on 8/30/2022 by associate director (Attachment #49). 08/30/2022 Implemented
6400.62(c)A viscous material consistent with hand soap was found in a decorative soap dispenser in Individual 3's bathroom.Poisonous materials shall be stored in their original, labeled containers. All poisons were locked on 8/30/2022 by associate director. Decorative soap dispenser was replaced by hand soap in its original container on 8/30/2022 (Attachment #50). 08/30/2022 Implemented
6400.64(a)Individual 3's toilet was found in an unsanitary condition, filled with yellow liquid and black material consistent with human waste and grime all around the toilet bowl. The bathroom had a strong urine smell.Clean and sanitary conditions shall be maintained in the home. Individual 3's bathroom was cleaned by residential coordinator on 8/31/2022 (Attachment #51). 08/31/2022 Implemented
6400.64(f)Trash bags and boxes were found on the ground next to garbage cans in the backyard.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.All trash bags were relocated to the appropriate trashcans on 8/31/2022 by residential coordinator (Attachment #52). 08/31/2022 Implemented
6400.110(c)There was no smoke detector located in a common area within 15 feet of Individuals 1 and 2's bedrooms. After the inspection, the agency provided a photo showing a smoke detector had been installed in the hallway.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. A new smoke detector was placed in the common area by Delta maintenance on 8/31/2022 (Attachment #53). 08/31/2022 Implemented
6400.111(c)The kitchen did not have a fire extinguisher. The nearest extinguisher was in the dining room. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Fire extinguisher was hung on the wall in the kitchen by Delta maintenance on 9/6/2022 (Attachment #54). 09/06/2022 Implemented
6400.144Pharmaceutical services are not being fully rendered. An over-the-counter bottle of generic acetaminophen was found in an unlocked kitchen cabinet. It was not labeled so it could not be determined if the medication belonged to or was being administered to any individual in the house. A staff member later indicated the medication was theirs. Individual 3's fluocinonide sol. 0.05% medication was expired, with an expiration date of January 2022. Individual 3's medication kit was also missing two PRNs called for on their MAR: banophen cap. 25mg, and benzoyl per gel 5%. The medications were not located in the home and as such were not available for the individual to use if needed.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. Bottle of generic acetaminophen was removed from the home by the residential coordinator on 8/29/2022. Individual 3¿s fluocinonide sol. 0.05% was re-orded by associate director and delivered to the home on 8/30/2022 (Attachment #55). Individual 3¿s two PRN medications were located in the home on 8/30/2022 and moved to the medication boxes for proper storage (Attachment #55). 08/30/2022 Implemented
6400.171An open package of smoked turkey was found in a storage freezer in the washroom.Food shall be protected from contamination while being stored, prepared, transported and served. Open package of turkey was removed by associate director on 8/29/2022 (Attachment #56). 08/30/2022 Implemented
6400.163(f)Individual 2's prescription arginine medication was found stored in the refrigerator alongside food, without a separate locked container.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.A medication lock box for the fridge was purchased and medications were safely stored in the locked box in the fridge by residential coordinator on 8/30/2022 (Attachment #57). 08/30/2022 Implemented
SIN-00091530 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On several occasions, Individual # 1's funds were used to pay for staff mealsIndividual funds and property shall be used for the individual's benefit. Individual funds shall be used for the individual's benefit. To ensure appropriate safeguards have been addressed, the team process will be used to approve expenditures for individual funds. The team will set limits for expenditures for costs associated with staff attending activities with the individual. The team will review this on an annual basis during the ISP meeting. Attachment # 47. For any expenditures that exceed the set limits agreed on by the team or for larger purchases, trips or memberships, the team process will be used to approve such expenditures on an individual basis. Attachment # 48. Team expenditure agreements went into effect 6/3/16 and a policy was written to provide guidelines to management staff 10/19/16. Attachment #49 06/03/2016 Implemented
6400.46(g)Staff # 4's annual fire safety training dated 10/15/2015 was not conducted by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Residential managers , Program Coordinators and Associate Directors participated in an annual fire safety train the trainer session on 10/14/16 Attachment # 16 completed by a fire safety expert Attachment # 17. Managers will participate in this training on an annual basis . Going forward, those managers trained as fire safety experts will complete face to face training for all staff at the homes where they work on an annual basis using the training materials provided by the fire expert Attachment # 18. . Any managers who were not in attendance will be trained by a fire safety expert by 11/30/16. Our trainer who was trained as a fire safety expert will train all new hires. 11/30/2016 Implemented
6400.151(c)(3)Staff # 4's physical examination dated 10/01/2014 did not document if the person was free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Delta secured a new occupational medical provider in an effort to improve contracted services on 4/1/16. Associate Director of Human Resources developed Staff Medical Examination Report Guidelines that are attached to each physical when the employee goes to their appointment, providing the medical examiner with instructions on information needed and for the form to be filled completely and correctly. Attachment # 37. The Human Resources Assistant and Human Resources Clerk are both responsible for checking each completed physical examination report to ensure it is filled out completely and correctly. 05/12/2016 Implemented
6400.168(a)Staff # 42's initial practicum observer training dated 03/11/2016 is invalid as the observations were incomplete. Staff # 43's initial practicum observer training dated 11/15/2013 is invalid as the observations 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 # 2's annual medication administration training dated 07/11/2015 was invalid as the third MAR review was completed on 09/16/2015 and fourth MAR review was completed on 12/06/2015. Staff # 3's annual medication administration training dated 04/15/2015 was invalid as the second MAR review was completed on 06/10/2015, the third MAR review was completed on 09/16/2015 and fourth MAR review was completed on 12/06/2015. Staff # 4's annual medication administration training dated 10/30/2015 was invalid as the fourth MAR review was completed on 12/06/2015.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