Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00271538 Renewal 08/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)Fire extinguishers were inspected 4/2/2024 and not again until 4/4/2025. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Kint Corp. is the designated vendor for annual fire extinguisher inspections across all programs. We have provided them with detailed information regarding our regulatory requirements and will coordinate inspection scheduling cycles to ensure full compliance. Kint Corp. has confirmed that they have updated our inspection date in their system accordingly. Attachment #2 08/22/2025 Implemented
6400.144Individual #1 has a PRN medication, Dulcolax (Bisacodyl) 5mg, with instructions to administer 2 tablets if they go 48 hours without a bowel movement. Individual #1 had a bowel movement on 7/21/2025 at 7:18am, then not again until 7/23/2025 at 7:00pm. This timeline exceeded 48 hours and Dulcolax was not administered. Individual #1 had a bowel movement on 7/25/2025 at 4:00pm, then not again until 7/28/2025 at 5:00am. This timeline exceeded 48 hours and Dulcolax was not administered. · Individual #1 has a PRN medication, Dulcolax (Bisacodyl) 5mg, with instructions to administer 2 tablets in they go 48 hours without a bowel movement. Individual #1 had a bowel movement, per the Bowel Movement Record on 7/28/2025 at 9:30pm. Per the Bowel Movement Record, Dulcolax was administered to Individual #1 on 7/30/25 8:45am - approximately 35 hours after the last bowel movement (not the required 48). Additionally, the July 2025 MAR shows another administration of Dulcolax on 7/30/2025 at 8:45pm, yet he previously had received Dulcolax at 8:45am and it is recorded there was a bowel movement on 7/30/2025 at 1:30pm.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. At this program, staff did not correctly calculate the required timeframe for administering medication following the absence of a bowel movement. As a result, the individual did not receive medication within the designated protocol window. To support staff in accurately calculating and documenting this, we are providing two updated resources: 1. Revised Bowel Movement Tracking Chart A new line has been added: ¿Next BM date/time due by:¿ Staff will use this field to record the exact date and time by which a bowel movement must occur. If no bowel movement is documented by that time, medication must be administered per protocol. 2. Bowel Protocol Timeline Quick Reference This reference tool outlines the required medication administration timeframes at 24, 36, and 48 hours. It is designed to help staff compute and enter the correct ¿due by¿ date/time on the Tracking Chart. Both of the above are submitted as Attachment #3. 09/01/2025 Implemented
6400.34(a)Individual #1 was not informed of their rights related to regulations 31a -- 31g on the Individual Rights and Responsibilities signed on 11/15/2024.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.On 8/19/25, the Individual Rights form updated to include items 31a through 31gwas signed by both the individual and their Guardian. A corresponding Checklist has been developed to accompany the Annual Packet distributed each November. Upon return, the Residential Secretary will review each packet for completeness and address any areas requiring follow-up 08/19/2025 Implemented
6400.165(e)At the time of the inspection (8/6/2025) a medication was noted on Individual #1's August 2025 Medication Administration Record (MAR) for PRN usage of Dexamethasone SP 4mg. This medication was discontinued on 6/8/2025 per doctor's orders, but it was not removed from the MAR.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.It was identified that the Acting Supervisor utilized a previously saved MAR from the computer, resulting in the prior months medication information being carried over into the current month without a thorough review against the individuals current medication orders. Although the individual did not receive any discontinued medications, this oversight underscores the need for strengthened review protocols. 09/01/2025 Implemented
6400.166(b)At the time of the physical site inspection (8/6/2025 at approximately 10:00am), the August 2025 Medication Administration Record recorded that Esomeprazole 40mg was administered to Individual #1 on 8/6/2025 at 6:05am, however there was no name or initials of the staff who administered the medication.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff have been retrained on the 15 Steps of Medication Administration. The Training Sign-In Sheet has been submitted separately for documentation. Attachment #6. As part of our ongoing plan to reduce medication errors, Supervisors have been reviewing the 15 Steps during monthly staff meetings to reinforce best practices, and will continue to do so. 08/19/2025 Implemented
SIN-00247586 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment began and ended on 6/6/2024. The self-assessment was not completed within the proper timeframe.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. We did not recognize we have been misreading the regulations regarding the timing of when the self-assessment is to be conducted. To correct that, our self-assessments will occur between 2/23/25 and 5/23/25, as our license date is 8/23/25, with a review upon receiving 30-day notice of licensing letter. 07/19/2024 Implemented
SIN-00214519 Unannounced Monitoring 10/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The tub in the "tub bathroom" had three pieces of pea size fecal matter at the drain of the tub; and also a thumb size of fecal matter in the middle of the tub.Clean and sanitary conditions shall be maintained in the home. Program Supervisor has adjusted the awake overnight chore list to include checking/cleaning the bathtub and a space for staff to initial when chore is completed. 11/20/2022 Implemented
6400.144Staff are not tracking individual #1's coffee/caffeine intake. Per individual #1's diet located in the 2022 menu at the home, it states he is to limit coffee/caffeine intake to two 4oz servings a day. Individual #2 is on a diabetic diet. Per Individual #2's diet located in the 2022 menu at the home, he should eat smaller, more frequent meals a day (5-6 meals a day). The documentation at the home does not reflect this.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The monitoring triggered conversations about the individuals and their diets. None of the current staff knew when/why the particular diets were implemented, so it was decided to consult with their PCPs to ensure the diets were needed and accurate. Individual #1's PCP was not the originator of the diet and had his own recommendations based on his treating the individual. Individual #2's PCP had made changes to the individual's medication a bit ago and he has been doing so well that he made changes to the diet also. Individual #1 had a PCP appointment on 11/9/22 where he changed his diet recommendations to be that he follow a regular diet; food should be cut into small bite sized moist pieces; staff are to encourage him to make healthy choices; to use a straw when drinking from a cup or bottle; should utilize a non-skid inter-lip plate; staff to ensure he always has a drink available while eating; staff to remind, when needed, to slow down, take small bites and to chew thoroughly; staff will remain in line of sight of the individual when he is eating. Individual #2¿s PCP changed his dietary recommendations due to his diabetes being well under control. PCP lowered his Metformin medication from 750mg 2x/day (1500mg total) to 500mg 1x/day. He is to follow a chopped moist diet; be offered 8oz of fluid at every meal and with medications; staff to remind, when needed, to chew his food completely before swallowing; Individual will occasionally cough once or twice while eating/drinking; staff monitor to ensure he is not choking and it is his `regular¿ cough; after coughing encouraged to take a drink before resuming eating his food; as he is a choking risk, staff will remain in line of sight of the individual when eating/drinking. 11/09/2022 Implemented
SIN-00107726 Renewal 04/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff #1's date of hire was 8/4/16 and FBI check was not until 3/13/17. Staff #2's date of hire was 6/8/16 and FBI check was not until 3/13/17. If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. The staff member responsible for completing all necessary pre-employment checks has been reminded by memo regarding the need for FBI checks if the applicant has not resided in Pa for at least the past two years. We have updated our checklist for new hires requiring the staff to fill in how long the applicant has lived in Pa, and whether an FBI check was needed or not. Please see submitted documentation for forms completed for recent hires. 04/26/2017 Implemented
6400.113(a)Individual #2 did not have fire safety training completed. There was a document in the record stating that he/she is deemed inappropriate for annual fire safety training. This document was reviewed on 5/15/15 and not again until 7/20/16. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Fire Safety training was provided to Individual #1 on 4/24/17. A general update was requested for Individual #1's ISP, and also an addendum was written for the Annual Assessment. Copies of both updates were sent to all team members. A memo was sent to all Residential Supervisors, Direct Care staff and Program Specialists reminding them of this requirement. (See submitted documentation) 04/26/2017 Implemented
6400.181(b)On 12/14/16 the doctor changed diet to include moist, soft, chopped food and then liquids 1/2 x 1/2 inch or 1/4 x 1/4 inch bite size small bites and sips and may need to restrict amount to 1 -2 ounces at a time. The addendum for individual #1 wasnt completed till 2/28/17. The assessement was done on 10/14/16. The addendum wasnt ent to all team members was only sent to the supports cordinator. If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. .A training was held for all Program Specialists reviewing all information necessary to be covered in Assessments and ISP Reviews on 4/27/17. Also an addendum was written for Individual #1's 2016 Assessment/Medical history. This addendum was sent to all team members. (See submitted documentation) 04/27/2017 Implemented
SIN-00205299 Unannounced Monitoring 05/12/2022 Compliant - Finalized
SIN-00188873 Renewal 06/22/2021 Compliant - Finalized
SIN-00132141 Renewal 04/23/2018 Compliant - Finalized