Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258391 Renewal 01/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff One has a date of hire of 7/10/23. Staff One had a physical exam conducted on that date, however Staff One came up positive on the Mantoux test. Staff One then had a chest x-ray conduced on 7/13/23, which is after the hire date of 7/10/2023. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. PAHrtners will ensure all new hired employees who require a Mantoux Tuberculin skin test receive the test and test results prior to working in the home providing direct care. It was determined during development of this PoC that the employee in question originally had a start date of 7/10/23, however, due to the delay in completing the physical, the start date was moved to 8/7/23. This has been corrected in the provider¿s HMIS system. 03/07/2025 Implemented
6400.46(b)Staff One's Fire safety training was completed more than a year apart.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).An audit of all employee fire safety training will be conducted to ensure there are no other employees who had received Fire Safety Training late. Audit of training records to be completed by 3/15/2025 by the Training Coordinator. 03/15/2025 Implemented
SIN-00243487 Unannounced Monitoring 04/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The exit to the outside for the deck on the second floor of the home has no lighting on the exterior of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. 1.a Work order to have light installed on the deck was submitted on 4/28/24. This was completed on 5/2/24. 05/02/2024 Implemented
6400.67(b)There was an accumulation of lint in the lint trap of the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.2.a The lint trap has been cleaned as of 4/26/24. 04/26/2024 Implemented
6400.68(b)The water temperature in the upstairs bathroom was 134 degrees. In the downstairs bathroom the water temperature was 138 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. 3.a. The hot water temperature was adjusted on 4/26/24 by maintenance. 04/26/2024 Implemented
6400.72(b)The window in individual #1's bedroom is broken. The weather stripping is broken off the window where it comes down to close into the windowsill. Staff relayed that the window was repaired prior to this inspection. However, this piece of the window remains broken since the repair was completed. Screens, windows and doors shall be in good repair. 4.a. Work order was submitted on 4/26/24 to have the window repaired and it was completed on 4/30/24. 04/30/2024 Implemented
6400.110(g)The bed shaker in the bedroom of individual #2 was not functional. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. 5.a. Maintenance was contacted on 4/26/24 upon discovery of the non-functional bedshaker. The bedshaker was fixed the same day. 04/26/2024 Implemented
SIN-00223831 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff (2) was hired on 1/3/2022, the criminal history check was requested on 8/24/2022. This request was conducted late. Staff (3) was hired on 6/3/2022 the criminal history check was requested on 8/24/22. This request was conducted late.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. All new hires are not permitted to start employment or be onboarded until their criminal history comes back cleared - this went into effect January of 2023. 01/01/2023 Implemented
6400.76(a)The window in bathroom #2 and in the kitchen were damaged, when opening the window would not stay open. Furniture and equipment shall be nonhazardous, clean and sturdy. The windows have been repaired by the maintenance team on 4/26/2023 (Attachment 04/26/2023 Implemented
6400.77(b)The First Aid Kit did not contain tweezers and scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit box has been stocked with all of the above by the Direct Support Supervisor and a check was completed at all other CLA homes to ensure all are stocked with the listed items. 06/07/2023 Implemented
6400.77(c)A First Aid Manual was not located in the first aid kit. A first aid manual shall be kept with the first aid kit.First aid manual was put in the first aid kit box by the Direct Support Mentor. 06/07/2023 Implemented
6400.82(f)There was no clean paper towels or cloth towels in bathroom #1 and #2.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. Paper towels and cloth towels were restocked in both bathrooms by the Direct Support Mentor. See attachments 17-20 04/12/2023 Implemented
6400.142(f)Individual 4 did not have a dental hygiene plan in the record.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The individual had his dental plan written and signed on January 6, 2023 - see attachment 22 01/06/2023 Implemented
6400.46(b)The fire safety training credentials were not provided.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).We obtained a copy of the fire safety expert's credentials on 4/12/23. See attachment 23 04/12/2023 Implemented
SIN-00211255 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)There was no adaptive equipment such as a bed shaker on individual 1's bed to be used when the fire alarm goes off and the individual is visually and hearing impaired.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. A safety work order was put in to maintenance to have the bed shaker installed in the individual room. In the meantime, staff will conduct checks in the room to ensure individual is safe. 11/04/2022 Implemented
6400.66The outside light outside of the laundry room was not operable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A work order was place with maintenance to have the outside light replaced/repaired. 11/04/2022 Implemented
6400.67(a)Bathroom near kitchen ceiling needs to be painted and the wall tiles were peeling. The mini blinds are broken and need to be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was place with maintenance to have the ceiling painted and repair wall tiles that are peeling. Mini blinds have been replaced with a new blind. 11/04/2022 Implemented
6400.72(b)The pantry door trim is coming apart. The Window slams shut and is unable to stay open in the laundry area and individual 2's bedroom door is damaged and needs to be replaced. Screens, windows and doors shall be in good repair. A work order was place with maintenance to repair the pantry door trim, repair the window and to replace the damaged bedroom door. 11/04/2022 Implemented
SIN-00207337 Renewal 04/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)10 of the 11 self-assessments completed were not completed 3-6 months prior to the license expiration date or 3-6 months after the last inspection 4/21.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. Provider created a self inspection spreadsheet with due dates and in the folder with the spreadsheet includes completed self-inspections form with the right form to use. 07/15/2022 Implemented
6400.112(c)The Fire drill dated 9/8/21-did not indicate the exit route used during the fire drill.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. Provider developed a visual step by step policy for residential managers to follow on how to properly conduct monthly fire drills. 07/18/2022 Implemented
6400.112(d)The Fire drill dated 11/9/21-indicates that the drill took 30 minutes and 70 seconds to evacuate the property. 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. Provider developed a visual step by step policy for residential managers to follow on how to properly conduct monthly fire drills. 07/18/2022 Implemented
6400.141(a)The individual did not have a physical examination within 12 months (annually), Individual #2 last physical was completed 09/15/2020 and most current conducted on 02/23/2022. (Doctor cancelled appointment and agency failed to take the individual to an appointment)An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Provider developed an Annual Physical Tracking spreadsheet to be maintained by the program specialist and care manager for current individuals and new admissions (as applicable). This spreadsheet includes previous date of last Annual Physical, with reminder of next due date of next annual physical. 07/18/2022 Implemented
SIN-00132604 Renewal 04/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dinning room table and one chair were scrapped. The cabinet door under the sink in the kitchen was splintered. The hallway wall on the second floor had a 30 inch long scrape.Floors, walls, ceilings and other surfaces shall be in good repair. A new dining table was ordered. 4 new chairs were replaced. The cabinet door under the sink has been repaired and no longer is splintered. 04/30/2018 Implemented
6400.73(b)The handrail on the second floor deck had damaged wood.Each porch that has over an 18-inch drop shall have a well-secured railing.The work order was submitted on 4/16/18. The work order has been completed as of 5/11/18. The wood was replaced, sanded and re-painted. 05/11/2018 Implemented
6400.185(a)Individual #2's annual ISP dated 10/18/17 was not implemented by the start date. The ISP shall be implemented by the ISP's start date. The Program Specialist reviewed all ISP and identified the annual ISP Date and revised the ISP outcomes to reflect the annual ISP Date and to use that date as a start date of the 90 day ISP Review 04/16/2018 Implemented
6400.186(a)Individual #2's annual ISP dated 10/18/17 was not reviewed every three months.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 reviewed all individual's 90 day plan and revised this individual's 90 day plan to reflect the correct time line starting with the Annual ISP Date. This individual's ISP annual date started at 10/18/17. His next 90 day review is 4/18/18. 04/16/2018 Implemented
SIN-00113967 Renewal 03/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1's previous physical was dated 7/23/13 and the next most recent was dated 2/15/16. Staff #2 previous physical was dated 8/16/11 and the most recent was dated 9/21/15. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Human Resource department has implemented a new protocol starting in 2016 where they will keep a spreadsheet of due dates of the physicals and send staff including the supervisor an e-mail notification 2 months prior to the expiration of the physical. The supervisors will assist the HR department to ensure that the staff completed his/her physical. 04/03/2017 Implemented
6400.151(c)(2)Staff #1's previous TB testing was dated 7/26/13 and the next most recent TB test was dated 2/15/16. Staff #2 previous TB testing was dated 6/21/13 and the most recent TB testing was dated 9/23/15. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Human Resource department has implemented a new protocol starting in 2016 where they will keep a spreadsheet of due dates of the due dates of each staff's TB testing and send staff including the supervisor an e-mail notification 2 months prior to the expiration of the TB testing. The supervisors will assist the HR department to ensure that the staff completed his/her TB testing. 04/03/2017 Implemented
6400.151(c)(3)Staff #1's physical dated 2/15/16 did not document if staff was free from communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Human Resources department roughly in middle of 2016 to start to scrutinize the results of the physical rather than just filing it to ensure that all information, including the part regarding communicable disease. If the communicative disease section is not complete, Human Resource sends the form back to the physician requesting competition of the form. 04/03/2017 Implemented
SIN-00087704 Unannounced Monitoring 11/12/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 10/10/15, physical abuse was founded by staff #1 against individual # 1An individual may not be neglected, abused, mistreated or subjected to corporal punishment. PAHrtners residential staff will receive training on abuse and de-escalating methods by an outside agency/consultant within 30 days of receipt of this plan of correction. Program Specialist will meet with staff monthly to discuss what is abuse, prevention, de-escalating methods and reporting procedures starting within 30 days of receipt of this plan of correction. The Program Specialist will conduct quarterly meetings with all Individuals of the program to allow the Individuals to discuss satisfaction with how they are being treated by staff, care and other service needs, documenting the discussions for review by the Department, starting within 30 days of receipt of this plan of correction. 02/23/2016 Implemented
SIN-00087530 Renewal 07/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34At the time of the inspection, the facility was unable to provide full access to all medication administration records requested. The electronic records were unable to be printed out to allow thorough review.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The team discovered that the medication administration in the current EMR system, Credible, can be printed. PAHrtners will soon be transitioning to a new EMR system, Quick MAR, that is easier to use. 02/15/2016 Implemented
6400.143(a)Individual # 1 refused Lamotribine 25mg, 7/4/15 at 6:00am, and there is no refusal plan in placeIf an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Refusal plan has been developed, in individuals progress notes, for individuals who tend to refuse medications. When an individuals refuses their medication staff provide counseling in this area and document information in individuals progress notes 08/05/2015 Implemented
6400.151(a)Staff # 1's physical examination was not being done every 2 years. Previous physical examination is dated 11/4/11 and the current physical examination is dated 2/14/14. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. HR department, including PAHrtners Office Manager and Assistant Office Manager, will contact staff 2 months before employees physicals are due, to give staff plenty of time to schedule their appointment. After a few weeks of communicating this information if staff has not responded the HR department will again make contact with staff. If employees do not attend to their physical exam by the their due date staff will be suspended from employment. Written protocol will be distributed to employees. 01/29/2016 Implemented
6400.151(c)(2)Staff #1's TB test was not done every 2 years. Previous TB examination was done 11/4/11 and the current TB test was done on 2/14/14. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. HR department, including PAHrtners Office Manager and Assistant Office Manager, will contact staff 2 months before employees TB tests are due, to give staff plenty of time to schedule their appointment. After a few weeks of communicating this information if staff has not responded the HR department will again make contact with staff. If employees do not attend to their TB test by the their due date staff will be suspended from employment. Written protocol will be distributed to employees. 01/29/2016 Implemented
6400.168(d)Staff # 1 and staff # 2 administered medication in July of 2015 but did not complete their medication administration practicum.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Procedures and guidelines for completing the medication practicum was reviewed with medication instructors. Instructors reviewed all staff charts. Staff our of compliance took the medication administration course again. Instructor developed a spreadsheet to keep track of the dates medication tests, observations and MAR documentation - indicating dates when future observations and MAR documentation are due. 10/15/2015 Implemented
6400.181(e)(6)Individual # 1's assessment dated 10/22/14 did not include the individual's ability to safely use poisonous substances.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. PAHrtners Program Specialist was trained in assessment requirements, program specialist was provided with the regulation indicating each area that must be included within the assessment including the ability to safely use poisonous substances. 01/06/2016 Implemented
6400.181(e)(7)Individual # 1's assessment dated 10/22/14 did not include the individual's knowledge of heat source.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. PAHrtners Program Specialist was trained in assessment requirements, program specialist was provided with the regulation indicating each area that must be included within the assessment including the individuals knowledge of heat sources. 01/06/2016 Implemented
6400.181(f)Individual # 1 had an ISP meeting dated 3/16/15 and there was no documentation that the assessment was sent to the team members prior to the ISP meeting.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). Program Specialist and the team were instructed and provided with a copy of the regulation regarding certain documentation, including the assessment, that must be submitted to team members at least 30 days prior to the ISP meeting. Program Specialist will be responsible to make sure submission of documentation is completed within the required time frame. 01/06/2016 Implemented
6400.185(a)Individual # 1's 3 months ISP review dated 2/16/15-5/12/15 was not implemented by the ISP start date of 4/25/15. The ISP shall be implemented by the ISP's start date. Program Specialist and the team have been taught that quarterly meetings must coincide with the ISP meeting. When a quarterly meeting is held on the same date as the ISP meeting, the next quarterly meeting will be scheduled 3 months (or before) from that date. Program Specialist will monitor dates of quarterly and ISP meetings. 07/15/2015 Implemented
SIN-00253938 Unannounced Monitoring 10/21/2024 Compliant - Finalized
SIN-00067127 Technical Assistance 08/12/2014 Compliant - Finalized