Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258390 Renewal 01/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)A chair located in the individual's bedroom is peeling, largely in disrepair and needs to be replaced. Furniture and equipment shall be nonhazardous, clean and sturdy. The damaged chair was removed from the home and a new chair purchased and placed in the bedroom. 01/11/2025 Implemented
6400.52(c)(5)The following staff who work with individual one did not receive training in the individual's behavior support plan from the behavior support specialist: Staff One, Staff Two, Staff Three, Staff Four, Staff Five.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.All staff who work with Individual One will receive Behavior Support Plan Training/Retraining by 3/21/2025. 03/21/2025 Implemented
6400.52(c)(6)The following staff who work with individual one did not receive training in implementation of the individual plan (ISP): Staff One, Staff Six, Staff Three, Staff Seven, Staff Four, Staff Eight, Staff Nine, Staff Five, Staff Ten, Staff Eleven.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.¿ All staff who work with Individual One will receive Individual Support Plan Training/Retraining by 3/21/2025. 03/21/2025 Implemented
SIN-00252252 Unannounced Monitoring 09/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)All 8pm medications that were administered to individual #1 on 9/21/24 were not documented as administered and those sections on the MAR were left blank.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The MAR was corrected on 10/4/24 to reflect that the individual received all of their 8pm medications on 9/21/24, and that the staff failed to document administering these medications. (Attachment 1) 10/05/2024 Implemented
SIN-00248600 Unannounced Monitoring 07/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were poisons unlocked in the home. The poison cabinet was unlocked in the kitchen, and there was antibacterial soap at the sinks.Poisonous materials shall be kept locked or made inaccessible to individuals. 1a. The poison cabinet has been locked and all antibacterial soaps/dish detergents were removed and replaced with non-toxic items. (see Attachment 1and 4) - Responsible Party: Program Manager 07/26/2024 Implemented
SIN-00211248 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32The Individual and staff did not have immediate access to the apartment's thermostat to regulate temperature.An individual may not be deprived of rights. Thermostat locked cover was removed to ensure accessibility by the member and staff. 10/25/2022 Implemented
6400.67(b)The lint trap in the dryer was full, which causes a potential hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint was removed. There is a notice on the dyer to remove lint after each use. 10/25/2022 Implemented
6400.77(c)The first aid kit did not contain a manual. A first aid manual shall be kept with the first aid kit.First Aid manual was added to the toolbox. The manual also has a label that states "do not remove" as a reminder to those using the toolbox to always put the manual back. 10/25/2022 Implemented
6400.163(a)As needed, also known as PRN, Medication prescribed to individual 1 was not labeled by the issuing pharmacy. The following medications did not have pharmaceutical labels on them: MUCINEX, EUCERIN, CETAPHIL, TOOTH & GUN CREAM, N-ACETYL CYSTERINE.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Medications that did not have pharmaceutical labels were removed. House manager is working with the agency nurse and individual's medical provider in obtaining a RX and refill. 10/25/2022 Implemented
6400.165(b)The Following Medication was not found in individual 1's medication box at time of inspection, (HYDROCORTISONE 1% CREAM, LOPERAMIDE 2mg, NEOSPORIN PLOSPAIN RELIEF 3.5mg)A prescription order shall be kept current.Refill was requested and obtained from pharmacy by agency nurse. 10/25/2022 Implemented
6400.195(b)The BSP and Restrictive Plan that were provided had not been reviewed at minimum every six months by the human rights team.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The plan was reivewed in April 25, 2022. The plan was not uploaded in the individuals file in a timely manner but now is uploaded. 10/25/2022 Implemented
SIN-00186235 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror located in individual 1's bedroom.In bedrooms, each individual shall have the following: A mirror. Provider purchased a new mirror for the individual's bedroom and had it installed. 05/19/2021 Implemented
SIN-00113966 Renewal 03/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The 2nd floor play room has dirt spot on the rug. The bathroom on tthis floor has evidence of mildew around the tub.Clean and sanitary conditions shall be maintained in the home. We did a work order and per the work order the carpet was shampooed on 5/4/17. The mildew treatment was completed on 4/28/17. The agency will do random checks of the apartment to ensure that there is no mildew. The agency will also do random checks of the apartment floor to ensure that the carpet is clean. 05/04/2017 Implemented
6400.67(a)The 2nd floor bedroom has access to the bathroom through a door. This door has no closure mechanism on the door knob.Floors, walls, ceilings and other surfaces shall be in good repair. This was Susquehanna Apt H; This was repaired on 4/25/17 by adding a mechanism to close the door on the door knob. 04/25/2017 Implemented
6400.112(c)The fire drill record dated 6/28/16 did not document if there were any problems encountered during the drill. The fire drill record dated 11/11/16 did not document if the fire alarm was operable.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The agency will ensure that the fire drill form is filled out completely before filing including the section about the operability of the alarm and complete the section where it asks if any problems were encountered 04/13/2017 Implemented
6400.112(d)The fire drill record dated 9/18/16 was not specific as to the time of evacuaion. Staff wrote "pass 2/1/2 minutes" 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 agency will ensure that the fire drill form is filled out completely before filing and the form will be more specific regarding long did it took for the members to evacuate. We will be putting exactly how many minutes and seconds it took for the individual to evacuate. 04/13/2017 Implemented
SIN-00087529 Renewal 07/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(a)First aid kit was not available for review at the time of site inspection.A home shall have a first aid kit. At the time of the audit the first aid kit was on site and was fully stocked. Unfortunately, staff took the key and we were unable to access the first aid kit. The Program Specialist will make sure that keys will be on site and available at all times. 07/10/2015 Implemented
SIN-00074783 Unannounced Monitoring 12/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(f)Individual #1 does not have free access at all times to the play room, where the individuals toys are stored, as it is locked.An individual has the right to receive, purchase, have and use personal property. Individuals will have full access to their personal items, common areas in their apartment and bedroom at all times. In the event an individual is agitated and presenting with dangerous behaviors, a restrictive plan will be developed to address that certain areas, containing objects that can be used as weapons, will be made inaccessible to the individual by locking the door to that area. Items, in open areas, that can be used as weapons, will be removed and locked up. When the period of agitation has ended and behaviors are no longer dangerous the locked areas will be unlocked, items in open areas will be returned. A typical timeframe for restricting access is approximately 30 minutes, unless the dangerous behaviors persists. Agitation and dangerous behaviors may include, but are not limited to the following: hitting, punching, pushing, kicking, biting, spitting, biting, throwing objects, using objects to hurt self or others and destroying property. 03/12/2015 Implemented
SIN-00065478 Renewal 06/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Self-assessment for the home was unavailable for review in the file.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self-assessment, 3 to 6 months before cert of compliance expires, has been added to the calendar for the program specialist to implement. Correction Date indicates the next date that the self-assessment is due before the expiration of certificate. 03/01/2015 Implemented
6400.183(4)Individual # 1 is on 1 to 1 supervision. The ISP, dated 5/14/14 did not include a protocol or schedule outlining specified periods of time for the individual to be without direct supervision.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. The Program Specialist will review all individuals of the homes ISP's to ensure that the staffing ratio schedules are included.ISP dated 5/14/2014 states "team will re-evaluate need for bedside 1:1 overnight and her 2:1 staff during awake hours at her residence after another 6mo. period". ISP meeting on 7/15/2014 reviewed staffing needs. The ISP was updated to include the schedule of staffing ratios to be followed for Individual #1. 07/15/2014 Implemented
6400.186(a)There were no quarterlies ISP reviews completed for Individual # 1.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The Program Specialist completed the ISP Quarterly reviews for Individual #1 and a schedule has been outlined to implemented the reviews on a 3 month schedule. Individual #1's quarterly meeting was held on 7/15/2014 to review the progress and growth. 07/15/2014 Implemented
6400.186(c)(1)There were no month ISP reviews completed for Individual # 1.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Monthly reviews have been outlined and implemented as of July 2014 for Individual #1. The Program Specialist will review Individual #1's progress and growth on a monthly basis prior to the quarterly reviews. The Program Specialist will review the monthly reviews on the 15th of each month to ensure that the reviews are completed timely. 07/01/2014 Implemented
SIN-00063576 Unannounced Monitoring 05/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)Individual #1 was abused by staff #1, when the staff backhanded the individual in the face after the individual spit on the staff. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Staff #1 was terminated from employment.The mother of individual #1 attending staff meeting on 5/15/2014 to share a family point of view on how families trust staff with their family members and how abuse and neglect impacts and hurts everyone involved. Reporting suspected abuse/neglect were reviewed. 05/29/2014 Implemented
6400.185(a)Individual #1's ISP was not implemented as written. Staff #1 did not follow the behavior plan as written. The ISP shall be implemented by the ISP's start date. Staff #1 was terminated from employment. Importance of following the ISP by start date had been reviewed with current staff, at staff meetings on 5/28/14 and 5/29/14. 05/29/2014 Implemented
6400.193(a)Staff #1 used an arm hold to restrain the indivdual after Individual #1 spit at them. A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. Staff #1 was terminated. Restrictive procedures were reviewed with current staff, during staff meetings on 5/28/14 and 5/29/14. 05/29/2014 Implemented
6400.195(f)Individual #1 was put into an arm hold. The arm hold and use of restraints was not written into their restrictive procedure plan. The restrictive procedure plan shall be implemented as written. Staff #1 was terminated. Current residential staff have taken T.A.C.T. refresher courses between February - May 2014, and was reviewed at staff meetings on 5/28/14 and 5/29/14. 05/27/2014 Implemented
6400.202(c)Individual #1 was put into an arm hold prior to less restrictive methods being attempted. Manual restraint shall be used only when it has been documented that other less restrictive methods have been unsuccessful in protecting the individual from injuring himself or others. Staff #1 was terminated. Current residential staff have taken T.A.C.T. refresher courses between February - May 2014. Staff were re-trained on less restrictive methods to use before implementing manual restraint, during staff meetings on 5/28/14 and 5/29/14. 05/29/2014 Implemented
SIN-00051560 Renewal 06/26/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #1 did not complete fire safety training during the 2012 training year.(g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Staff #1 completed their fire safety training on August 1, 2013. Fire marshal is scheduled to provide the training several times per year.Each staff member is scheduled annually. We will video tape the next training to be offered at the end of October 2013 , to serve as a back-up if staff are unable to attend their scheduled training. Supervisor is responsible to insure each staff attends the training yearly. 09/16/2013 Implemented
SIN-00248596 Unannounced Monitoring 07/26/2024 Compliant - Finalized
SIN-00132603 Renewal 04/10/2018 Compliant - Finalized