Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00289273 Unannounced Monitoring 06/01/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was dishwashing liquid under the unlocked kitchen sink. Poisons should be kept locked and not accessible to the individuals.Poisonous materials shall be kept locked or made inaccessible to individuals. The dishwashing liquid was immediately locked during the unannounced licensing visit. 06/30/2026 Implemented
6400.64(a)There was a package of chicken fully wrapped in its original container in the oven. The chicken was still partially frozen, and the oven was not on. Food should be defrosted in the refrigerator.Clean and sanitary conditions shall be maintained in the home. Immediate Action: Immediately following the unannounced visit, the program manager threw the package of chicken away, and a training was immediately conducted with staff member #1 and all staff on duty. 06/30/2026 Implemented
6400.163(a)The electronic Medication Administration Record (eMAR) for individual #1 did not include pharmacy labeled containers. The items were Melatonin 3mg and Head and Shoulders Shampoo. The Culturelle Digestive Health 10 billion cell-200mg capsule was listed in the eMAR at 8am, but the strength was omitted on the information sheet, which served as the medication box label.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Immediate action: An email was sent to individual #1 parents informing them moving forward that all topical and non-topical medications will need to be supplied by pharmacy. Melatonin 3mg, head and shoulder shampoo, and Culturelle Digestive Health 10 billion cell-200 MG capsule were re-ordered for individual 1 on 6/11/2026. 06/30/2026 Implemented
6400.163(h)The Erythromycin 2% gel label had an expiration date of 5/21/2026 and had been administered June 1, 2026, but it should have been destroyed in a safe manner according to applicable Federal and State statutes and regulations.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Immediately after the unannounced licensing inspection visit, the expired Erythromycin gel was safely discarded and re-ordered by nursing. 06/30/2026 Implemented
6400.165(b)Some medications for the individual #1 were not currently available in the residence to be dispensed as prescribed: Benzoyl Peroxide Cleanser 10% was empty, and empty blister packs were found for Fluvoxamine Maleate Tab 50mg (8am and 8pm).A prescription order shall be kept current.Immediately after the licensing inspection, nursing was contacted and Fluvoxamine 50 MG tablet, Benzoyl peroxide cleaner 10% were ordered and added to individual #1 eMAR. 06/30/2026 Implemented
6400.165(c)The electronic Medication Administration Record (eMAR) for the individual #1 and medication label had mismatched prescription instructions. · The Mupirocin 2% ointment was administered for longer than the prescriber intended. The label read "Apply to red spots on right thigh and lower right and left arms in armpit area every morning and evening for 7-10 days". The date it was filled was 12/04/25. A staff member #1 signed having administered it on June 1, 2026 at 8am. · The Benzoyl Peroxide Cleanser 10% was listed in the eMAR at 8am, but the medication label read 8pm. · The eMAR for the individual #1 instructed the 8am dose of Levothyroxine Sodium 50mcg tablet be "take[n] one tablet by mouth daily before breakfast at (7am) for Hypothyroidism", but the medication label read "Take one tablet by mouth daily before breakfast (7am) for hypothyroidism". This may cause a medication error (6400.167(a)(4) if administration occurs longer than the 1 hour allowed after the prescribed time. · The Eucerin Intensive Repair Lotion eMAR 8am instructions read "Apply to body once daily after shower", but the medication label read "Apply to affected area topically twice a day as needed for dry skin.A prescription medication shall be administered as prescribed.Immediately following the licensing inspection visit, a review of individual #1 eMAR was conducted by nursing. The nurse updates the eMAR to reflect the 7 AM Levothyroxine sodium 50 mcg tablet. The Benzoyl Peroxide 10% cleanser and the Eucerin Intensive Repair Lotion time were updated in the eMAR to reflect the scheduled prescribed by individual #1 PCP. 06/30/2026 Implemented
6400.166(a)(1)The electronic Medication Administration Record (eMAR) for the individual #1 did not include any PRN medications. Items not included on the eMAR were Acetaminophen 650mg caps, Ammonium Lactate Lotion 12%, Petroleum Jelly, Saline Mist 0.65% Nose Spray, Ketoconazole Shampoo 2%, Vani Cream Conditioner, and Clinical Moisture Skin Cream. Staff shared that the individual's parents provided some of these items and they were stored with the other medications although they were not on the eMAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:Immediately following the licensing inspection, the following PRN medications were added to individual #1 eMAR Acetaminophen 650mg caps, Ammonium Lactate Lotion 12%, Petroleum Jelly, Saline Mist 0.65% Nose Spray, Ketoconazole Shampoo 2%, Vani Cream Conditioner, and Clinical Moisture Skin Cream. An email was sent to all to individual #1 parents informing them that all meds prescribed for individual #1 should be provided by pharmacy. 06/30/2026 Implemented
6400.166(a)(10)The electronic Medication Administration Record (eMAR) for the individual #1 listed a 5pm Vascepa 1 gram capsule dosage, but the medication label had 4pm written on the packaging.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Immediately following the licensing inspection, the pharmacy was contacted to update the 5p med administration time label to the medication on the packaging. 06/30/2026 Implemented
6400.166(a)(11)The electronic Medication Administration Record (eMAR) for the individual # 1 mostly omitted the diagnosis or purpose for the prescribed medications, including pro re nata.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1's physician order sheet was reviewed by nursing with all prescribed physicians, and the diagnoses were added and sent to Altruix pharmacy on 6/11/26 to add to individual #1 eMAR. 07/15/2026 Implemented
6400.166(d)The electronic Medication Administration Record (eMAR) for the individual #1 listed an 8am dosage of Erythromycin 2% gel as "Apply to affected area every evening", but the prescription label read "Apply to affected area every morning".The directions of the prescriber shall be followed.Immediately following the licensing visit, the nurse updates the eMAR to reflect the evening application of the erythromycin 2% to reflect the scheduled prescribed by individual #1 PCP. 06/30/2026 Implemented
6400.167(a)(1)The electronic Medication Administration Record (eMAR) for the individual #1 was initialed by staff member #1 and included a red asterisk; however, dosages for Benzoyl Peroxide Cleanser 10% and Fluvoxamine Maleate Tab 50mg were not available in the home during the inspection.Medication errors include the following: Failure to administer a medication.Immediately following the licensing inspection, dosages for Benzoyl Peroxide Cleanser 10% and Fluvoxamine Maleate Tab 50mg were ordered by nursing. 06/30/2026 Implemented
SIN-00283721 Renewal 02/24/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(c)Documentation for Staff One did not reflect a documented case-by-case hiring review related to criminal charges or prior convictions in relation to the position for which the staff was hired.The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire. Staff member 1 had up-to-date clearances upon hire and at the time of licensing review within 1 year of hire. The PA criminal background check for Staff 1 was completed on 12/4/25 and the assessment was completed on 12/17/25. Pease see attached background check and assessment. 04/30/2026 Implemented
6400.62(a)Poisons were found unlocked throughout the house. The ISP for Individual One states they "do not have access to any cleaning products or hazardous materials," and "Merakey does ensure that all cleaning products are safely locked." The ISP for Individual Two states, "(They) need an environment where poisonous substances are appropriately secured."Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. 04/30/2026 Implemented
6400.62(d)Boost drinks were found stored alongside liquid laundry detergent, zep cleaner, and hand soaps in the freestanding closet in the basement living area. This was corrected at the time of the visit.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.All poisonous materials were locked and/or removed from areas with food upon discovery during the audit. 04/30/2026 Implemented
6400.67(a)The office ceiling was damaged from what appeared to be a water leak. Staff reported the leak occurred the previous week, and a maintenance request was submitted; however, the request was not provided for review.Floors, walls, ceilings and other surfaces shall be in good repair. Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to fix the office ceiling. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented
6400.68(b)Water temperatures in the home consistently measured over 120 degrees Fahrenheit notably in the kitchen (133 °), main hallway bathroom (132.4°), Individual Two's bathroom (129.4°), and basement bathroom (129.7°). Hot water temperatures in bathtubs and showers may not exceed 120°F. Program leadership submitted a maintenance request immediately to Merakey's facilities Department the day of the licensing audit to fix the water temperature at Jody Ln. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented
6400.80(a)The rear porch egress and stairs were not cleared of snow. This was in process of being corrected at the time of the visit. Outside walkways shall be free from ice, snow, obstructions and other hazards. Staff removed snow on the walkways at all the exits upon discovery during the audit. 04/30/2026 Implemented
6400.82(f)Individual Two's bathroom did not have toilet paper or individual paper towels or cloths. Staff stated that the individual will use them to clog the toilet, so they were locked in the hallway supply closet. When the individual needs toilet paper, they use the call button next to the toilet to notify staff; however, this is not stated in the individual's ISP.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Immediately after the licensing audit, the Program Specialist emailed the Support Coordinator to schedule a critical revision of individual #2 ISP. 05/15/2026 Implemented
6400.111(e)The home is three (3) stories including the basement and attic. There was one smoke detector on each floor; however, the detectors were not interconnected. A fire extinguisher shall be accessible to staff persons and individuals. Program leadership submitted a maintenance request to Merakey's facilities Department the day of the licensing audit to ensure that all detectors in the house are interconnected. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. 04/30/2026 Implemented