Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217100 Renewal 12/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.103The most recent furnace cleaning was completed on 11/23/2021.Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept.The provider had a furnace inspection completed on 12/22/2022. (Proof of the furnace inspection will be emailed to the licensing supervisor). 01/22/2023 Implemented
SIN-00128492 Renewal 01/31/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.23(a)Family Member #1, date of birth 11-8-75, did not submit a criminal history check prior to Individual #1 living in the home on 6-14-17.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home.a Provider/Family Members compliance file has been developed. Program Specialists compiled a list of each provider and household members documenting past and current dates for physical (with TB testing) and clearances. That file will be reviewed semi-annually if there were no admissions during that time. An index was developed showing the current dates for all the providers. The semi-annual reviews will be documented and any action taken will be noted. Before an individual can be admitted to the LifeSharing program, both specialists will review that provider's personnel file to assure that all household members are in compliance with the physical, TB and clearance regulations. It will then go to the Clinical Director/RN for final approval prior to accepting an individual for placement. [Family member #1 had a Pennsylvania criminal clearance submitted on 2/8/18. Documentation of aforementioned reviews shall be kept. (AS 4/24/18)] 03/01/2018 Implemented
6500.125(a)Family Member #2, date of birth 12-10-12, had a physical examination completed 6-27-15, and Individual #1 began living in the home on 6-14-17.Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home.a Provider/Family Members compliance file has been developed.. Program Specialists compiled a list of each provider and household members documenting past and current dates for physical (with TB testing) and clearances. That file will be reviewed semi-annually if there were no admissions during that time.. An index was developed showing the current dates for all the providers. The semi-annual reviews will be documented and any action taken will be noted. Before an individual can be admitted to the LifeSharing program, both specialists will review that provider's personnel file to assure that all household members are in compliance with the physical, TB and clearance regulations. It will then go to the Clinical Director/RN for final approval prior to accepting an individual for placement. [Family member #2 had a physical examination completed 2/2/18. Documentation of aforementioned review shall be kept. (AS 4/24/18)] 03/01/2018 Implemented
SIN-00077810 Renewal 01/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self-assessment did not indicate when it was completed; therefore, compliance could not measured.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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.PROCEDURE: 1. Program Specialists will coordinate the self-assessment of either the Residential (6400) or Family Living (6500) programs annually in preparation of our Licensing Inspection dates. 2. Self-assessments are to be completed using the Licensing Inspection Instrument Scoresheet. 3. Program Specialists are not to complete self-assessments on their own assigned houses but will assess the houses of a different Program Specialist. 4. The self-assessments are to be completed within three (3) to six (6) months prior to the expiration date of the Certificate of Compliance. 5. When the self-assessments are scheduled, the Program Specialist will inform the Clinical Director and Residential Director of the date so that compliance with the stated time frame can be assured. 6. Upon completion of the self-assessment, the Program Specialist will make a copy of the assessment, along with the Licensing Inspection Scoresheet, listing the Summary of Non-Compliance areas, giving the original to the Program Specialist whose house they assessed and the copy to the Residential Director. 7. Program Specialists are to rectify the Non-Compliance Areas in order to show a score of 100% at the licensing inspection. 8. Once the scoresheet is corrected and the house is at 100% the Program Specialist is to submit the scoresheet to the Residential Director to review and approve. [Immediately, the Residential Director will review the current Certificate of Compliance to determine the required timeframe for completing self-assessments of the homes and will implement a procedure to ensure all family living homes self-assessments are competed timely. The aforementioned staff involved in competing the self-assessments will be trained on required timeframes, documentation to include date competed; as well as, aforementioned procedures. (AS 4/13/16)] 03/09/2016 Implemented
6500.73The outside steps, which exceeds two steps, on the side of the home do not have a handrail.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.The provider is having the steps removed, which will be completed by April 30, 2016. [Immediately and at least quarterly the family living specialist will complete an onsite visit to all family living homes to ensure all interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps have a well-secured handrail. Documentation of all family living home visits shall be kept. (AS 4/13/16)] 03/09/2016 Implemented
6500.182(c)(3)On 1/22/16, Individual #1's most recent gynecological examination, completed on 4/2/15, was not in individual #1's record. Each individual's record must include the following information: Physical examinations.After the completion of an annual examination when tests have been ordered by the physician, the Program Specialist will contact the doctor approximately 7-10 days after the test to find out the results. If no results are in, the Specialist will call every 2 days until the results have been reported. [Immediately and at least quarterly, the family living specialist will review all individuals' records to ensure all required information is present including physical examination and will immediately obtain missing information. Documentation of the record reviews shall be kept and reviewed by residential director to ensure completion and that all required information in present in all individuals' records. (AS 4/13/16)] 03/09/2016 Implemented
SIN-00041959 Renewal 09/05/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.43(d)Staff #1 was not informed of the following program specialist responsibilities: (1) Coordinating and completing assessments. (Partially implemented-adequate progress-CEM-1/28/2013) (2) Providing the assessment as required under § 6500.151(f) (relating to assessment). (3) Participating in the development of the ISP, including annual updates and revisions of the ISP. (4) Attending the ISP meetings. (5) Fulfilling the role of plan lead, as applicable, under § § 6500.152 and 6500.156(f) and (g) (relating to development, annual update and revision of the ISP; and ISP review and revision). (6) Reviewing the ISP, annual updates and revisions for content accuracy. (7) Reporting content discrepancy to the SC, as applicable, and plan team members. (8) Implementing the ISP as written. (9) Supervising, monitoring and evaluating services provided to the individual. (10) Reviewing, signing and dating the monthly documentation of an individual¿s participation and progress toward outcomes. (11) Reporting a change related to the individual¿s needs to the SC, as applicable, and plan team members. (12) Reviewing the ISP with the individual as required under § 6500.156. (13) Documenting the review of the ISP as required under § 6500.156. (14) Providing the documentation of the ISP review to the SC, as applicable, and plan team members as required under § 6500.156(d). (15) Informing plan team members of the option to decline the ISP review documentation as required under § 6500.156(e). (16) Recommending a revision to a service or outcome in the ISP as provided under § 6500.156(c)(4). (17) Coordinating the services provided to an individual. (18) Coordinating the support services for the family. (19) Coordinating the training of direct service workers and the family in the content of health and safety needs relevant to each individual. (20) Developing and implementing provider services as required under § 6500.158 (relating to provider services). The family living specialist shall be responsible for the following:Staff #1 has been informed of her responsibilities as a program specialist. Staff #1 verified through signature. All program specialists were trained in their responsibilities and verified through signature. Verification through staff signature has been forwarded. Responsibilities of 6500.43(d) have been added to the job description for future hires. Agency Director will be responsible for implementation. 12/07/2012 Implemented
SIN-00256426 Renewal 11/19/2024 Compliant - Finalized
SIN-00235783 Renewal 11/29/2023 Compliant - Finalized
SIN-00199621 Renewal 02/03/2022 Compliant - Finalized
SIN-00169256 Renewal 01/13/2020 Compliant - Finalized
SIN-00149665 Renewal 01/15/2019 Compliant - Finalized