Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272634 Renewal 08/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed on 07/24/24, and then again on 08/20/25. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Mainstay Life Services understands that 6400.141(a) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 10/01/2025 Implemented
6400.34(a)Individual #1 was informed and explained their rights on 01/01/24, and then again on 01/23/25. This exceeds the annual requirement.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Mainstay Life Services understands that 6400.34(a) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 10/01/2025 Implemented
6400.165(g)Individual #1 has been prescribed medications for treatment of a psychiatric illness. Individual #1 had psychotropic medication reviews completed on 07/05/24, 11/21/24, 04/07/25, and 08/01/25. Each psychotropic medication review for Individual #1 exceeds the every 3 month requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Mainstay Life Services understands that 6400.165(g) was out of compliance and cannot be brought back into compliance. However, Mainstay Life Services will implement systemic and procedural actions to prevent recurrence. 09/16/2025 Implemented
SIN-00179479 Renewal 11/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(d)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. Direct Service Worker #1 was observed in the home wearing a mask under his/her chin that were not covering his/her nose and mouth at 10:32AM on 11/18/20. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual shall be treated with dignity and respect.Individuals shall be treated with dignity and respect by staff wearing masks properly during the entirety of service provision. As of November 19, 2020, Mainstay Life Services updated the COVID Guidelines in accordance with local government and CDC guidance. The COVID Guidance was emailed to all staff on November 19, 2020 stating masks must be worn correctly (over nose and mouth) indoors, regardless of social distancing. This applies to all staff, including administration working at the Roessler office. Masks may be briefly removed to drink or eat while maintaining social distancing. Disciplinary procedures must be followed if masks are not worn accordingly. Program coordinators and program managers were retrained on 11/24/2020, on the updated COVID Guidelines including staff wearing face coverings properly as required during the entirety of service provision. Training was conducted by Director of Quality and the Director of Residential Operations. Immediate disciplinary action was taken for all staff that were not properly wearing a mask. Going forward, COVID Guidelines will be reviewed again with all staff at the December site staff meetings. Any infractions of this policy may lead to disciplinary action up to and including termination of employment. Supporting documentation includes, COVID Guidelines as of November 19 2020, the training signature sheet for the guidelines, and the example of the disciplinary form that will continue to be utilize. 11/25/2020 Implemented
SIN-00119668 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Melatonin tablet, 3 mg take 1/2 tablet (1.5 mg) by mouth at bedtime, prescribed for Individual #1 was not logged as administered on 6/27/17. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. A prescribed medication was not logged on the MAR as administered on 6/27/17. A documentation error form was completed. Staff was retrained on Medication Documentation procedures with a focus on completion of documentation which includes putting initials in the box by the time and the date on the MAR after the medication is administered as per the PA DPW Medication Administration Manual. Medication supervisors have been instructed to make sure all documentation is completed according to procedures when the meds are reviewed bi weekly, and documented on the back of the MAR. Supporting documentation will be submitted. [Five staff persons signed training document on 8/28/17 and 8/30/17 for aforementioned training. (AS 9/1/17)] 08/31/2017 Implemented
SIN-00230515 Renewal 09/06/2023 Compliant - Finalized
SIN-00069651 Renewal 09/10/2014 Compliant - Finalized