Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258785 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment of this home on 1/10/2025 which was not completed during the 3 to 6 months prior to the expiration of the Certificate of Compliance or 6 to 9 months after the previous year's inspection. Additionally, the following sections of this self-assessment were left blank and not assessed for compliance: staffing, staff health, home services, day services/recreational and social activities, restrictive procedures, individual records, nine or more individuals, emergency placement, respite care, and semi-independent living.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. The agency is creating a schedule for each house to have a complete self-assessment within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance to measure and record compliance. 01/17/2025 Implemented
6400.113(a)Individual #1, date of admission 10/22/2024, had no documentation of being instructed in the individual's primary language or mode of communication 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. 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. The agency will create a checklist for emergency placements that last longer than 30 days. The checklist will include an individual¿s primary language or mode of communication, general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place outside the building. 01/29/2025 Implemented
6400.141(c)(6)Individual #1, date of admission 10/22/2024, last had a Tuberculin test by Mantoux method on 06/01/2022.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Emergency placements lasting longer than 21 days will be scheduled for a Tuberculin test by Mantoux method along with their physical before the 30 days are accounted for. 01/17/2025 Implemented
6400.181(a)Individual #1, date of admission 10/22/2024, did not have an initial assessment completed at the time of inspection. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Each individual will have an initial assessment completed 1 year prior or 60 calendar days after admission to residential homes and updated annually. The program specialists will complete the assessment and update as needs change. 01/29/2025 Implemented
6400.34(a)Individual #1, date of admission 10/22/2024, was informed of their rights and the process to report a rights violation on 01/13/2025. No prior documentation was provided.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.Individual rights and the process will be added to an annual checklist and set up in the electronic health record with reminders 60 days before they are due to be signed again. 01/29/2025 Implemented
SIN-00170824 Renewal 02/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The program specialist provided Individual #1's assessment, dated 11/1/19, to the plan team members on 11/5/19 for the annual ISP meeting held on 11/26/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The current Residential Program Specialists will be trained in the area of 55 PA Code Chapter 6400.181(f) with a focus on providing the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting by February 26, 2020 by the Residential Program Director. The Residential Program Director will monitor and log all completed initial and annual individual assessments to ensure that all assessments are completed in accordance with the regulations. [Documentation of a half hour of training for 5 staff persons on 2/25/2020 provided to the Department. Documentation of aforementioned monitoring will occur on a spread sheet that will be updated at least monthly by the Director of Residential Services. (AES,HSLS on 2/27/20)] 02/26/2020 Implemented
SIN-00130807 Renewal 03/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for fire drills held on 12/14/17 and 8/20/17 did not include the amount of time it took for evacuation.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. On May 22, 2018 all House Managers, Clinical Director, Clinical Supervisor and the Program Director reviewed the 6400.112 requirements. Fire drills were conducted the week of May 28, 2018 through June 1, 2018. In services for all staff were held May 23, 29,30, June 1,4,6,8 to review the record of fire drill and fire equipment checks. An example was used for staff to complete the form in its entirety. When the fire drill and Fire equipment check is completed after each fire drill, it is to be submitted to their supervisor by the next business day. The House manager will review the form to assure compliance to the regulation. The house manager will verify that the form is complete and accurate by signing and dating the form. It is then given to the Clinical Director who reviews and approves it by signing and dating the form. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur. Effective Date: June 1, 2018 Responsible Party: Program Director, House Manager, Compliance Officer [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
SIN-00110357 Renewal 03/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The basement of the home did not have a smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. a smoke detector was installed in the basement. Direct care staff are required to complete a fire drill every month. During the drill staff is required to check all detector and fire extinguishers to assure they are in working order. That finding will be documented on the Fire Drill form. Managers review the fire drill report each month to make sure of compliance. [Immediately and at least quarterly, a designated management staff person shall complete an onsite check of all community homes to ensure there is an operable automatic smoke detector on each floor, including the basement and attic. Documentation of the checks shall be kept. (AS 4/21/17)] 03/26/2017 Implemented
6400.113(a)Individual #1, date of admission 8-06-2016 was instructed in fire safety on 9-27-2016. 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. Once the Manager receives the Intake/Admission form approving the admission, they will use the New Admit checklist to make sure that all required documents, exams and evals are completed in the stated time frames. The Clinical Director will review the checklist prior to giving the approval for the individual to be admitted. [Immediately and at least quarterly for 1 year, a designated director shall review the new admission checklist and fire safety training documentation to ensure all individuals are instructed in fire safety as required, timely. Documentation of all reviews shall be kept. (AS 4/21/17)] 03/26/2017 Implemented
6400.141(a)Individual #1, date of admission 8-06-2016 had a physical examination completed on 8-23-2016.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. New intakes will be processed by the Clinical Director, who will make sure that all required and verifying documents are received and checked prior to any new admission. The Intake/Admission form will be signed and become part of the individuals case file. The Clinical Director will assure that the admission does not take place until the regulatory requirements are met [Immediately and at least quarterly for 1 year, a designated director shall review the new admission checklist and physical examinations to ensure all individuals have a physical examination completed, timely. Documentation of all reviews shall be kept. (AS 4/21/17)] 03/26/2017 Implemented
SIN-00201576 Renewal 03/08/2022 Compliant - Finalized