Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238318 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)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 drill conducted on 6/14/23 at 6:30 am had an evacuation time of 2 min 49 seconds. This exceeds the requirement. 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. Program Specialist and staff will be trained on the Chapter 6400.112 Fire Drills regulation by 3/28/24. 03/22/2024 Implemented
6400.141(c)(14)Individual #1's physical examination dated 6/22/23 did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Nursing will attend individual's physical appointments to ensure physical paperwork is appropriately filled out by the physician. 03/22/2024 Implemented
6400.32(r)(4)An individual has the right to lock the individual's bedroom door. The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. Individual #1 had a "pin key" lock on their bedroom door at the time of inspection, this type of lock does not allow for immediate access.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Individual #1-bedroom door locked was changed on 3/14/24 and a key was given to individual #1. Attachment # 8 03/22/2024 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. Individual #1 had a 3-month medication reviews on 12/19/23 and the form used did not document or include the reason for prescribing the medication.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.Medication list attached to appointment forms will ensure to include the diagnosis to the medications that are prescribed. Attachment # 9 03/20/2024 Implemented
6400.166(a)(11)Individual #1's March 2024 Medication Administration Record (MAR) did not include the diagnosis or purpose for their medication Tussin 10 ML every 4 hours PRN. Agency staff did add the diagnosis for the medication to the MAR during the inspection once the licensing representative discussed the missing diagnosis and purpose on the MAR.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.Diagnosis was added to the MAR for Tussin 10 ML 3/6/24. 03/22/2024 Implemented
6400.213(1)(i)213(1)(ii): Individual #1's individual's record did not contain identifying marks as the body marks section of their record was left blank.Each individual's record must include the following information: Identifying marks.Individual's face sheet was updated with the identify marks on 3/20/24. Attachment # 11 03/20/2024 Implemented
SIN-00200577 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(1)Staff #1 did not receive annual training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationship in the 7/1/20-6/30/21 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #1 will complete the training of person centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships by 5/20/2022. 05/20/2022 Implemented
6400.52(c)(5)Staff #1 did not receive annual training on the safe and appropriate use of behavior supports in the 7/1/20-6/30/21 training year.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.Staff #1 will complete the training on safe and appropriate use of behavior supports by 5/20/2022 in regards to the 55 PA Code Chapter 6400.52 (c )(5). 05/20/2022 Implemented
6400.52(c)(6)Staff #1 did not receive annual training on the Implementation of the individual plan in the 7/1/20-6/30/21 training year.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.Staff #1 will complete the Implementation of the individual plan by 5/20/2022. 05/20/2022 Implemented
SIN-00167154 Unannounced Monitoring 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(12)This area wasn't assessed in Individual #3's assessment dated 4/15/2019. Repeat Violation: 1/15/2019.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Specialist completed individual¿s recommendations for specific areas of training, programming and services by 12/20/2019. See Attachment 9. Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020. All Assessments will be reviewed and updated for accuracy by Program Specialist by 1/31/2020. A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 10. 03/01/2020 Implemented
6400.181(e)(13)(viii)This area wasn't assessed in Individual #3's assessment dated 4/15/2019. Repeat Violation: 1/15/2019.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Program Specialist completed individual¿s current progress and growth in managing personal property by 12/20/2019. See Attachment 9. Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020. All Assessments will be reviewed and updated for accuracy by Program Specialist by 1/31/2020. A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 10. 03/01/2020 Implemented
6400.165(g)Individual #3 is prescribed Fluoxetine for Depression. She was admitted on 3/15/2019. She has not had any Psychiatric Medication reviews since her admission.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.Individual 3 had an appointment with a physician appt on 12/19/2019. See attachment 8. Cynthia will continue to have psychiatric medications to be monitored by her physician every 3 months. Program Specialists will be trained of necessity to have psychiatric medications monitored every three months by Martha Gonzalez, Director of IDD Residential Services by 1/15 2109. 12/19/2019 Implemented
SIN-00147624 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Individual #2's MAR was not always filled out immediately after each individual's dose of medication. The following errors were noted: 08/01-08/05/18 -- No signature for Latuda 80mg to be administered at bedtime. 09/05 -- No signature for Latuda 80mg to be administered at bedtime. 09/17 -- No signature for Hydrocortisone @ 9pm. 09/20 -- Missing signature for the 7am administration of Denta 5000. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. ¿ Program Specialist will retrain staff on following medication administration policy and guidelines by 1/31/2019. See Attached # 8 ¿ Ongoing, Program Specialist will ensure staff understand and adhere to medication administration policies and guidelines. Program Specialist will address with staff if policy and guidelines are not followed. 02/16/2019 Implemented
6400.167(b)Individual #2's meds were not administered as directed. The following errors were noted: On 09/21 8pm Oyst Cal/ Vit D 500/200 was not given at 4pm. They called the nurse at 8pm, she said to hold off until the 9pm dosage since it was so close to being administered. On 11/02 -- Hydrocortisone 1% was not administered, but signed for. Finally, Individual #2's MAR states she is to get five drops of neo/poly ear drops 2x daily starting on 11/12 before a medical appointment. According to the MAR, it was not administered at 7am on 11/12 because were no neo/poly ear drops present at the house. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.¿ Program Specialist will retrain staff on following medication administration policy and guidelines by 1/31/2019. See Attached # 8 ¿ Ongoing, Program Specialist will ensure staff understand and adhere to medication administration policies and guidelines. Program Specialist will address with staff if policy and guidelines are not followed. 02/16/2019 Implemented
6400.181(e)(9)On the section of Individual #2's assessment that deals with documenting the individual's disability, all that was written was "Mild IDD"···but the physical form listed many other conditions and diagnoses.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. ¿ Program Specialist completed individual¿s # 2 Assessment related to disability, including functional and medical limitations by 2/15/2019. See Attached # 6, page 2. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(10)There was no lifetime medical history or any medical history at all listed in Individual #2's assessment.The assessment must include the following information: A lifetime medical history. ¿Program Specialist will attach a life time medical history to the Assessment for Individual #2 by 2/14/2019. See Attached # 7. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(12)There were no recommendations made in Individual #2's file.The assessment must include the following information: Recommendations for specific areas of training, programming and services. ¿ Program Specialist completed individual¿s # 2 recommendations for specific areas of training, programming and services by 2/15/2019. See Attached # 6, page 42 ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019 03/31/2019 Implemented
6400.181(e)(13)(i)Individual #2's progress and growth in the last 365 days was not addressed in the area of health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 2-5 ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(ii)Individual #2's progress and growth in the last 365 days was not addressed in the area of motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 6-8. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(iii)Individual #2's progress and growth in the last 365 days was not addressed in the area of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 8-12, 18-23. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(iv)Individual #2's progress and growth in the last 365 days was not addressed in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 5, page 35. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(v)Individual #2's progress and growth in the last 365 days was not addressed in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 34-35. ¿ Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(vi)Individual #2's progress and growth in the last 365 days was not addressed in the area of recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 34-35. ¿ Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(vii)Individual #2's progress and growth in the last 365 days was not addressed in the area of financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached #6, page 30. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(viii)Individual #2's progress and growth in the last 365 days was not addressed in the area of managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. ¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 18-20. ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(e)(13)(ix)Individual #2's progress and growth in the last 365 days was not addressed in the area of community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.¿ Program Specialist completed individual¿s # 2 for progress and growth by 2/15/2019. See Attached # 6, page 23-24, 42 ¿ Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 3/15/2019. ¿ All Assessments will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.181(f)There is no documentation in Individual #2's file that would indicate the assessment was sent to the SC and team at least 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Director of IDD Residential Services , Martha Gonzalez will assure Program Specialist are retrained in providing The Assessment to the SC and the plan team members at least 30 calendar days prior to an ISP meeting by 3/15/2019. ¿ All documentation of Assessment distribution will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
6400.186(a)Individual #2 had a late quarterly. They were completed on 03/22/18, 06/22/18, 07/19/18, then not again until 12/22/18. There was a five month gap between the July and December reviews.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. Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The ISP and 3 month or more frequent review & documentation with signatures by 3/15/2019. ¿ All ISPs and 3 month or more frequent reviews will be reviewed and updated for accuracy by Program Specialist by 3/31/2019. 03/31/2019 Implemented
SIN-00129459 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)There is no record of Individual #1 having breast exams performed.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. ¿ The Asst. Director of Health Care is responsible for scheduling breast exams annually. The Director of Health Care will review the appointment dates when they are scheduled to ensure that they do not exceed this requirement. Individual #1 had a physical on 2/26/18 at which time a breast exam was attempted. Individual #1 refused. A copy of that physical is attached. See also Desensitization Plan. (Please see attached #8). ¿ A calendar reminder has been set to schedule the appointment timely. ¿ The Asst. Director of Health Care is responsible for scheduling Breast Exam annually ¿ The process is effective immediately and will be ongoing as needed. 03/28/2018 Implemented
6400.186(a)Individual #1 had ISP reviews on 6/20/17, 7/20/17, 1/12/18, and 1/18/18. The time frame between 7/20/17-1/12/18 exceeds the 3 month requirement.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. ¿ Program Specialist completed the ISP Review for Individual #1 and obtained signatures on 01/18/2018. (Please see attached #7). ¿ Program Specialist will continue to complete individual¿s ISP Reviews on a quarterly basis as required. ¿ The program Specialist will be responsible to ensure individual¿s ISP Reviews are completely and up to date ¿ Completed by 3/28/18 and ongoing basis as required. ((Program Specialist will be re-trained in the requirements of regulation 6400.186 regarding ISP Reviews. Documentation of this training will be kept. - CH 4/10/18)) 03/28/2018 Implemented
SIN-00108275 Renewal 02/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #1's assessment was developed on 06/29/16 and the ISP meeting was on 06/30/16, so the assessment was not provided 30 days prior to the ISP meeting date. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). A checklist is developed to assure scheduling compliance with availability of the Assessment to the SC and plan team members at least 30 days before the ISP meeting. See Attached 1. Training will be conducted with all Program Specialists regarding the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP by Martha Gonzalez, Director of Community Support Services by May 15, 2017. 05/15/2017 Implemented
6400.186(b)Individual #1's reviews were not signed or dated.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Individual #1¿s ISP Reviews have been and will be signed and dated by the Individual and the Program Specialist. See Attached 7. All ISP Review Signature Sheets will be reviewed/updated to assure signature by Individual & Program Specialist by 4/28/2017. House Audit Checklist by Coordinator/Specialist is updated to include at least monthly audit of individual¿s record to include ISP Review signatures. See Attached 4. Training regarding Individual and Program Specialist ISP Review signature will be conducted with Program Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. Attached is an ISP Review and Signature Sheet that shows Program Specialist and Individual signature. See Attached 8. 05/15/2017 Implemented
6400.213(1)(i)Indivdual #1's file photo was not dated. Also, the section pertaining to identifying marks was left blank.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1¿s Face Sheet is updated to include identifying marks. See Attached 5. Individual #1¿s File Photo was updated with date. See Attached 6. All individual¿s records will be updated to include identifying marks and a current, dated photograph by 4/28/2017. House Audit Checklist by Coordinator/Specialist is updated to include at least monthly audit of individual¿s record to include identifying marks and a current, dated photograph. See Attached 4. Training regarding Individual¿s records will be conducted with Program Specialists by Martha Gonzalez, Director of Community Support Services by 5/15/2017. 05/15/2017 Implemented
SIN-00071380 Renewal 11/13/2014 Compliant - Finalized