Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260252 Renewal 02/06/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1 was admitted on 6/17/24 and the initial assessment was completed on 10/24/24 which was outside of the regulatory 60-day date. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual #1 had her initial assessment completed on 10/24/2024, outside of the 60-day time frame. A memo was provided to Director of the CLA program on 2/7/2025, which details time-frames and due dates for move-ins to the CLA program (Attachment 1 6400.181(a) Move-in process review memo ). 02/07/2025 Implemented
6400.32(a)The current rights statement signed on 12/3/24 by individual #1 and others does not include all of the regulatory rights.An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age.The Individual Rights was updated and reviewed with each resident on 2/7/2025. All residents signed the updated Individual Rights form and signed documentation was filed within the residents program book (Attachment 2 6400.32(a) Individual Rights for all residents ). 02/07/2025 Implemented
6400.166(a)(4)The MAR for Individual #1 did not have their Epinephrine 0.3mg/0.3mL SOAJ PRN listed. The pharmacy was immediately contacted, and the MAR was updated during the inspection.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.MAR was corrected to reflect Epinephrine 0.3mg/0.3mL SOAJ PRN on 2/6/2025. (Attachment 3 6400.166 (a)(4) M.D.MAR 2.2025). Community Care Pharmacy was contacted to add Epinephrine 0.3mg/0.3mL SOAJ PRN to monthly MAR sheet. (Attachment 4 6400.166(a) M.D. MAR 3.2025) 02/07/2025 Implemented
SIN-00238940 Renewal 02/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1 did not have a physical examination every 2 years, previous physical was completed 12/20/21 and not completed again till 01/03/2024. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Policy on Health Appraisals was amended by Deputy Director (Attachment 6400.151 A). Policy and Procedure states: HR Department will provide staff members three months notice before Staff Health Appraisal is due. Deputy Director and Director will be copied on the email to ensure communication. Director will complete follow-up communication two months before due date. Employees are required to notify Director of their scheduled appointment. Employees will turn in Health Appraisal to the HR Department. HR Department will notify Director and Deputy Director of submission of completed health appraisal. Employees who do not have a completed Health Appraisal by the due date will be placed on suspension without pay until a completed Health Appraisal is obtained. All staff members signed updated policy and procedure (Attachment 6400.151 B). 03/24/2024 Implemented
6400.169(d)A summary record of training for staff #1 shows she requalified but failed to sign as completed. (Training record not completed/documented correctly)A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.A memo was provided to all staff indicating that Medication Certification paperwork will be reviewed on a quarterly basis by Deputy Director, Director and Program Coordinator for completeness and accuracy. Failure to complete needed information by scheduled due date will result in suspension of medication certification until certification is reinstated with completed and received paperwork (Attachment 6400.169 A). Memo was signed by all staff (Attachment 6400.169 B). Paperwork missing signature was signed by staff member (Attachment 6400.169 C) 04/01/2024 Implemented
SIN-00219037 Renewal 02/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1's last dental exam is dated 1/2021.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. A memo to Medical Coordinator was provided on 2/21/2023 (Attachment E) indicating necessary medical appointments and tracking system to ensure compliance. Individual #1 is scheduled to go for a dental exam on 3/3/2023. A review of all staff files was completed on 2/21/2023 and all other dental records are in compliance. 03/03/2023 Implemented
SIN-00199788 Renewal 02/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(c)There was no operable automatic smoke detector located in the hallway, the hard wire detector was damaged, and the manual detector was missing.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. A request for repair was completed on 2/9/2022. The repair was completed on 2/14/2022. (Attachment 7- picture of repaired smoke detector) 02/24/2022 Implemented
6400.111(f)There was a Fire Extinguisher located in the entrance hall closet was not inspected annually, the extinguisher was last inspected March 2016. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguisher was removed from the residence on 2/9/2022 and returned to fire extinguisher company (Attachment 8- picture of closet without fire extinguisher) 02/24/2022 Implemented
6400.112(a)The fire drill was missing the fire drill for August 2021 at time of inspection and exit. An unannounced fire drill shall be held at least once a month. The fire drill was completed as scheduled and sent to inspectors following exit conference. The fire drill in question is attached (Attachment 10- completed August fire drill). 02/23/2022 Implemented
6400.112(d)The fire drill completed on 12/11/21 took 5 minutes to evacuate. 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. The fire drill record has been modified to reflect apartment number and sleep/awake for residents. The fire drill record has also been modified to include a spot for initials for review by program coordinator and program director, to ensure compliance with evacuation time. 02/24/2022 Implemented
6400.141(c)(10)It was unable to be determined if the individual had a communicable disease that had a need for specific precautions. Section was omitted on examination for Individual #1The 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. Medical Coordinator reviewed documentation with Primary Care Physician . "Communicable Diseases" box was appropriately checked off and dated on 2/11/2022 (Attachment 11) 02/11/2022 Implemented
6400.166(a)(13)The medication record was not kept, 8am medication for Individual #1 did not contain the initial of the person that administered the medication. (The medication was given just not signed as administered)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.STAFF completed medication administration policy re-training as indicated on 2/24/2022 and signed medication administration record. (Attachment 13, MAR signed correctly and Nadine re-trained CLA Medication Administration Policy and Procedure). 02/24/2022 Implemented
6400.166(d)Medication Stomach Relief 525mg for Individual #1, had a prescription label stating medication was to be used by 01/22/2022. Medication was not discarded. The directions of the prescriber shall be followed.The directions of the prescriber shall be followed.The Stomach Relief Medication (525 mg) for Individual #1 was discarded on 2/9/2022. New medication was received from the pharmacy on 2/25/2022. 02/25/2022 Implemented
SIN-00182604 Renewal 01/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1's financial documentation from January until June of 2020 shows monies being disbursed for purposes that were not clearly indicated.(2) Disbursements made to or for the individual. Policy and Procedure for Disbursement of Client Funds was issued on 2/1/2021. Program Coordinator will complete transactions on Financial Ledger that will be specific to purchases made by clients. Disbursements made directly to the individual will be clearly notated on the ledger. Residential staff will track receipts to ensure clear documentation of purchases. Significant purchases will be reviewed with treatment team members. Attachment 6400.22(d)(2): Program Coordinator job description, Policy and Procedure Disbursement of Client Funds, individual #1 updated financial ledger for February 03/01/2021 Implemented
6400.67(a)The walls in the main bathroom were peeling on the surface. The shower knob controlling the water is damaged.Floors, walls, ceilings and other surfaces shall be in good repair. Service requisition was submitted by Director on 1/14/2021. On 1/26/2021, repair of the bathroom wall and shower knob was completed. Senior Resident Advisor will complete a safety walk-through of the home weekly, utilizing Weekly Site Inspection Sheet. A memo was issued to all Administrative Staff on completing Self-Assessment of apartments (utilizing ODP Self-Assessment Tool) on a quarterly basis, dated 1/27/2021. Any identified needs during walkthrough will be submitted to Program Director for submission for repairs. Attachment 6400.67(a): weekly walk-thru, memo regarding self-assessment dated 1/27/2021, Senior Resident Advisor job description; picture 6400.67(a) bathroom wall 01/27/2021 Implemented
6400.142(a)According to NECC records, individual #1 has not been to the dentist since 10/4/17. A follow up was scheduled for 10/4/18 but this was not indicated in the record. Director states that the primary doctor does a mouth check at the annual physical. Current ISP for individual #1 states that there are yearly cancer screenings by Penn Dental and that she is seen annually.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Dental exam was completed on 1/27/2021 at 9AM. Medical Coordinator/Senior Residential Advisor will track and monitor medical appointments for residents, included in her job description. Dental hygiene plan was created following dental appointment. Staff were trained on dental hygiene plan. Attachment: 6400.142(a): individual #1 dental exam, dental hygiene plan, Senior Resident Advisor job description. 02/27/2021 Implemented
6400.142(f)Individual #1's annual assessment dated 12/10/2020 does not inform on what type of care is needed in the area of oral hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Senior Resident Advisor scheduled a dental exam for individual #1. Dental exam was completed on 1/27/2021 at 9AM. Dental hygiene plan was completed following dental appointment. Staff were trained on updated dental hygiene plan for individual #1. Attachment: 6400.142(f): individual #1 dental exam, dental hygiene plan 02/27/2021 Implemented
6400.144Individual #1's medications Diphenhydramine 50mg, Triple Antibiotic Ointment, Loperamide and Acetaminophen were unavailable at the time of the medication review.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. Policy and Procedure for CLA Monthly Medication Review was implemented and disbursed on 1/27/2021. Pharmacy was contacted for verification on medications prescribed and medications discontinued. Director will review MARs and medications for accuracy on a monthly basis. Attachment: 6400.144: Policy and Procedure Monthly Medication Review, individual #1 MAR for February 02/01/2021 Implemented
6400.181(d)Individual #1's annual assessment dated 12/10/2020 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment. Annual Assessment was completed and not dropped into Shared Drive. Program Director will complete audits of program books on monthly basis to ensure completion of needed documentation. Attachment: 6400.181(d) individual #1 Annual Assessment signed. 02/01/2021 Implemented
6400.163(h)Individual #1's medication Earwax Remover Drops had expired on 2/19/2020 and was still being used for medication administration.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Policy and Procedure for CLA Monthly Medication Review was implemented and disbursed on 1/27/2021. Earwax Remover Drops were transported to Orleans Building on 1/27/2021 to Nurse for disposal per Federal and State Regulations. Attachment: 6400.163(h) Policy and Procedure Monthly Medication Review 01/27/2021 Implemented
6400.166(a)(4)Individual #1's medication box contained Physicians Care Eye Drops which were not included on the current medication administration record for this individual.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Deputy Director updated Policy and Procedure on CLA Monthly Medication Review. Pharmacy was contacted for verification on medications prescribed and medications discontinued. New Policy details review of medications and MARs for accuracy. Attachment: 6400.166(a)(4) Policy and Procedure Monthly Medication review, individual #1 MAR for February 02/01/2021 Implemented
SIN-00154236 Renewal 04/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The first aid kit contained a packet of Imodium A-D.Poisonous materials shall be kept locked or made inaccessible to individuals. On 4/18/19, Imodium was removed from the First Aid kit by Senior Residential Counselor. The required contents and corresponding regulations pertaining to all First Aid kits were reviewed with all staff members by 4/19/19 (see Memo Attachment B). Ongoing monitoring of First Aid kits will be conducted on a weekly basis by assigned staff by completing Inventory Tracking Sheet (Attachment C). Attachment D has staff training record for new policy and procedure. Senior Residential Counselor will review tracking sheet on a weekly basis to assure compliance (Attachment E). All First Aid kits were inspected. 04/19/2019 Implemented
6400.77(a)The first aid kit was incomplete not containing items to make up a complete kit. (Thermometer, Gauze, tape). A home shall have a first aid kit. On 4/18/19, medical tape, thermometer and gauze were placed in the First Aid kit by Senior Residential Counselor. The required contents and corresponding regulations pertaining to all First Aid kits were reviewed with all staff members by 4/19/19 (see Memo Attachment B). Ongoing monitoring of First Aid kits will be conducted on a weekly basis by assigned staff by completing Inventory Tracking Sheet (Attachment C). Attachment D has training record for all staff on new policy and procedure. Senior Residential Counselor will review tracking sheet on a weekly basis to assure compliance (Attachment E). All First Aid kits were inspected. 04/19/2019 Implemented
SIN-00128229 Renewal 01/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)STAFF #1 DID NOT COMPLETE A MEDICATION PRACTICUM BETWEEN 05/2016 AND 01/04/2017.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Immediately, all staff persons who administer prescription medication to individuals shall complete and pass the Medication Administration Practicum course annually. On 1/24/2018, staff person #1 received MAR and Observation Training by Senior Resident Advisor /Medication Administration Trainer, (see attachment #4). On 1/24/2018 an updated Medication Training Tracking System was implemented and will be utilized on an ongoing basis to record all staff MAR and Observations as required and to insure that this violation does not occur in the future. (see attachment # 5) Program Director will review all training through weekly supervision sessions with Medication Administration Trainer where updated Medication Training Tracking System will be presented. Program Director has reviewed all remaining staff files to assure compliance with MAR and Observation training. 02/06/2018 Implemented
SIN-00108219 Renewal 01/09/2017 Compliant - Finalized