Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249901 Renewal 08/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 had a receipt for McDonald's on 6/20/2024 in the amount of $8.36, however the financial record documented that the amount spent was $8.35, which made the ending and starting balances inaccurate up until this inspection period. During the walkthrough of the home, the money ledger still inaccurately reads the balance as $21.71, when is should read $21.70. The ledger was checked by supervisor/staff on 6/24, and 6/28.(2) Disbursements made to or for the individual. On 8/21/2024, the Residential Services Supervisor corrected the June 2024 financial ledger (attachment #12) to reflect the correct balance of $21.70. 09/03/2024 Implemented
SIN-00114089 Renewal 06/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Cleaning supplies, 2 cans of Lysol spray and 1 can of scrub free total bathroom cleaner were unlocked in the hallway closet. Poisonous materials shall be kept locked or made inaccessible to individuals.A lock was installed on the closet door (attachment #35). The Residential Director will train Program Managers and House Managers on the importance of ensuring poisonous materials are locked or made inaccessible to individuals by 9/30/2017. The Program Manager will retrain staff and House manager at Millersburg on their responsibility in ensuring that all sprays and cleaners are kept locked at all times. The House Manager will conduct random weekly audits to ensure all poisonous materials are locked, and this will be documented on the Program Monitoring Tool (Attachment #12). The House Manager will submit the monitoring tool to the Program Manager monthly. The Program Manager will conduct random audits twice a month for compliance, and will document on the Program Monitoring Tool (Attachment #12). The Residential Director will conduct random audits on locked poisonous materials. 09/30/2017 Implemented
6400.103There is no emergency shelter listed in the emergency evacuation plan. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The emergency evacuation plan was updated to ensure to list the emergency shelter, staff responsibilities, and means of transport in the emergency evacuation plan for individual #1 (attachment # 19). The Residential Director will retrain the Program Managers and House Managers on the importance of including the emergency shelter location, staff responsibilities, means of transportation and an emergency shelter location to the emergency evacuation plan by 10/30/17. The Program Managers will review all of the emergency evacuation plans for the individuals in their service area to ensure that the emergency shelter is listed on the plan. Any non-compliance will be corrected by 9/15/2017. The Program Manager and the House manager will be responsible for ensuring compliance. The Program Manager will review the emergency medical plan and track it annually on the Annual Consumer Compliance Checklist (attachment #26). The Residential Director will randomly review 2 emergency medical plans per quarter to ensure compliance and track on the Residential Director¿s tracking log (attachment #8). 10/30/2017 Implemented
6400.106The home has a gas furnance with hot water radiators. There is no documentation on record that the filter has ever been changed. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director of Facilities and Maintenance will keep a record of the cleaning to ensure compliance. The Residential Director will review and retrain the Program managers and House Managers on the importance of ensuring that the furnace cleaning records are maintained by 9/30/17. The Director of Facilities has contracted with a certified contractor to complete annual cleaning (attachment # 34). The Director of Facilities will ensure that all furnaces and HVAC are inspected and cleaned annually and the filters are changed quarterly. The furnace will be serviced/cleaned and the filter changed by 10/15/17. 10/15/2017 Implemented
6400.113(a)Individual #1 received fire safety training on 6/11/2015 and not again until 7/6/2016. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The Residential Director will review with, and retrain all House Managers and Program Managers on the importance of ensuring that an annual fire safety training is conducted annually for each of their individuals by 9/30/17. The House Manager will complete the Annual Consumer Compliance Checklist (attachment # 26) for the individuals in their care by 9/15/17, and the House Manager will make any corrections necessary to address non-compliance. The Program Manager will review the completed Annual Consumer Compliance Checklist (attachment # 26) to ensure compliance 2 times a year. To ensure compliance the Residential director will review this 2 times during the year to ensure compliance, this will be tracked on the Residential Directors tracking log (attachment # 8). 09/30/2017 Implemented
6400.145(1)No emergency medical plan contained in record. The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The location of the hospital for individual #1 was added to the emergency medical plan (attachment # 19). The Residential Director will retrain the Program Managers and House Managers on the importance of including the location of the hospital on the emergency medical plan by 10/30/17. The Program Managers will review all the emergency medical plans for the individuals in their service area to ensure that the location of the hospital is indicated. Any non-compliance will be corrected by 9/15/2017. The Program Manager and the House manager will be responsible for ensuring compliance. The Program Manager will review the emergency medical plan and track it annually on the Annual Consumer Compliance Checklist (attachment #26). The Residential Director will randomly review 2 emergency medical plans per quarter to ensure compliance and track on the Residential Director¿s tracking log (attachment #8). 10/30/2017 Implemented
6400.145(2)No emergency medical plan contained in record. The home shall have a written emergency medical plan listing the following: The method of transportation to be used. The location of the hospital for individual #1 was added to the emergency medical plan (attachment # 19). The Residential Director will retrain the Program Managers and House Managers on the importance of including the location of the hospital on the emergency medical plan by 10/30/17. The Program Managers will review all the emergency medical plans for the individuals in their service area to ensure that the location of the hospital is indicated. Any non-compliance will be corrected by 9/15/2017. The Program Manager and the House manager will be responsible for ensuring compliance. The Program Manager will review the emergency medical plan and track it annually on the Annual Consumer Compliance Checklist. The Residential Director will randomly review 2 emergency medical plans per quarter to ensure compliance and track on the Residential Director¿s tracking log (attachment #8). 10/30/2017 Implemented
6400.145(3)No emergency medical plan contained in record. The home shall have a written emergency medical plan listing the following: An emergency staffing plan.The emergency medical plan was updated to include the staffing plan for individual #1 (attachment # 19). The Residential Director will retrain the Program Managers and House Managers on the importance of including the location of the hospital on the emergency medical plan by 10/30/17. The Program Managers will review all the emergency medical plans for the individuals in their service area to ensure that include the staffing plan. Any non-compliance will be corrected by 9/15/2017. The Program Manager and the House manager will be responsible for ensuring compliance. The Program Manager will review the emergency medical plan and track it annually on the Annual Consumer Compliance Checklist (attachment #26). The Residential Director will randomly review 2 emergency medical plans per quarter to ensure compliance and track on the Residential Director¿s tracking log (attachment #8). 10/30/2017 Implemented
SIN-00077965 Renewal 02/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Telephone in the living room did not have emergency numbers on or by the telephone. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The regulation was reviewed with the Program Manager and House Managers on 4/29/2015 (Attachment #7). House Manager placed emergency numbers on the base of the phone in the living room (Attachment #8) and Program Manager will check quarterly to ensure all homes have emergency phone numbers on or by the telephones. 04/29/2015 Implemented
6400.151(c)(2)Individual #1 did not have current tuberculin test. There was no dates for a previous tuberculin skin test as well. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The regulation was reviewed with the Program Manager and House Managers on 04/29/2015 by the Assistant Director (Attachment #5). Individual #1 was seen by her PCP to attempt TB testing but attempt failed when consumer became uncooperative as written on doctor's note (Attachment #6). Individual #1 has a consult at Hershey Medical Center on 6/25/2015 to be sedated for several medical procedures, including tuberculin skin testing. 07/01/2015 Implemented
6400.162(a)Individual #1's chotrimozale 1% cream was not in the orginal label. Staff wrote PRN on the label. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Program Manager and House Managers were trained on the regulation on 4/29/2015 by the Assistant Director (Attachment #3). Review of Module 5 of Administering Medications the Right Way student manual dealing with PRN medications was conducted with the House Managers by the Assistant Director on 4/29/2015 (Attachment #4). The prescription medicine that had PRN written on the label was discontinued by the doctor on 1/6/2015 and returned to the pharmacy on 2/23/2015. 04/29/2015 Implemented
SIN-00156530 Renewal 06/24/2019 Compliant - Finalized
SIN-00067700 Initial review 08/28/2014 Compliant - Finalized