Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258786 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 from 12/18/2024 through 1/8/2025 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, Plan Development/Process/Content, Home Services, Day Services, 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
6400.151(a)Program Specialist #1, date of hire 12/9/2024, completed their initial employment physical examination on 12/13/2024. 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 will ensure that everyone will have a physical within the 12 months prior to employment. 01/17/2025 Implemented
6400.151(c)(2)Program Specialist #1, date of hire 12/9/2024, completed their initial employment tuberculin skin test on 12/13/2024. 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 will ensure that everyone will have a TB 12 months prior to employment. 01/17/2025 Implemented
6400.34(a)Individual #1 was informed of their individual rights and the process to report a rights violation on 1/5/2024 and again on 1/13/2025.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
6400.44(c)(2)Program Specialist #1, date of hire 12/9/2024, possesses a bachelor's degree but does not have the pre-requisite 2 years of experience working directly with individuals with intellectual disabilities or autism.A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.Program Specialist #1 is now a house supervisor, and the residential director will take on the caseload until pre-requisites for experience are met. 01/17/2025 Implemented
6400.165(g)Individual #1's psychiatric medication reviews were completed on 4/2/2024 and again on 7/17/2024.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.The individual¿s psychiatric medication review dates will be added to the electronic health record with alerts to the program coordinators and PC supervisor to ensure each review is done at least every 3 months, including documenting the reasons for prescribing the medication, the need to continue and the necessary dosage. 01/29/2025 Implemented
6400.169(a)Direct Service Worker #2 completed their last annual medication administration practicum on 3/17/2023. Direct Service Worker #2 completed Medication Administration Record reviews on 3/30/2023 and 1/8/2024 as well as one medication administration observation on 9/21/2023; however, the second medication administration observation was not completed within the annual timeframe. Remediation, including one Medication Administration Record review and one medication administration observation, was not completed until 1/7/2025. According to the Medication Administration Training Program Annual Practicum Remediation Chart, Direct Service Worker #2 would have needed to complete two additional observations by 5/16/2024 to remain compliant. According to testimony provided by Residential Director #3, Direct Service Worker #2 has continued to administer medications without meeting the annual training requirements.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).The Direct Service Worker #2 completed their medication administration training on their next worked shift on1-26-25. They did not pass medications until they completed their entire medication administration course. 01/26/2025 Implemented
SIN-00201577 Renewal 03/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(2)Individual #1's financial record indicated a cash balance of $332.22. Individual #1's cash-on-hand totaled $318.17. Individual #'1's financial record was absent of any documentation to account for the difference. The agency receives funds from Individual #1's representative payee to use on their behalf. Individual #1 is unable to manage their own finances as indicated in their 4/17/21 assessment and 6/3/21 individual plan. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. Upon Individual #1's return to the home on 3/9/2022, the direct care staff confirmed with Individual #1 that $15.00 had been received earlier in the day for personal spending and the appropriate receipt documentation was completed and recorded into the record (proof of receipt will be emailed to licensing supervisor upon plan submission) CFO, Tiffanie Rodgers, completed an audit on individual petty cash funds on 3/10/2022 to verify all fiscal records for accuracy and thoroughness (summary statement and finance report to be emailed to licensing supervisor upon plan submission) A new and comprehensive training - Management of Individual Funds - was assigned to the Duffy house staff (operates on 3 block shifts = Carrie Burdine and Tina Anderson with the 3rd block currently open) for completion by March 31, 2022. This training includes that if the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual - for a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. (Proof of training completion will be emailed to licensing supervisor on April 1, 2022) 03/25/2022 Implemented
SIN-00149895 Renewal 02/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 2-13-19 at 1:4PM, the hot water temperature at the shower on the main floor of the home measured 137.8 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 2/13/19, RPW Tina Anderson manually turned down the thermostat on the hot water tank at this residence and took the temperature approximately 2 hours later, which registered at 117.3 degrees. The staff at this residence have continued to monitor the hot water temperature each day since 2/13/19 and the temperatures have consistently remained below 120 degrees Fahrenheit. Staff will continue to monitor the water temperature in accordance with the most current procedure for doing so and will adjust the temperature down if any readings exceed 120 degrees, will take the temperature 1-2 hours later and if still above 120 degrees, will contact a maintenance person immediately to seek professional assistance with any repairs/replacements that are needed at that time. The 3 block staff of this residence will receive training on how to properly take a water temperature reading and how to document it and report any discrepancies/issues to maintenance that are needed by April 1, 2019. Water temperature documentation for all other residential programs were also reviewed to ensure that all reading are at or below 120 degrees Fahrenheit and all others were noted to be in compliance.[Fire Safety/ Fire Drill Hot Water Temperature Monitoring Procedure Training documentation for Program Specialist training on 3/14/19 submitted to the Department on 3/18/19. (AES,HSLS 3/19/18)] 04/01/2019 Implemented
SIN-00110358 Renewal 03/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The interior stairs leading to the basement did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Non skid surface will be applied to the stairs. A column to check all stairs will be added to the monthly staff checklist so that stairs can be assessed regularly on the status of the non skid surface. Managers will verify on their House Visit Log that both staff and the Manager checked the stairs on a monthly basis. [Immediately, nonskid surface shall be applied to the basement stairs and a picture submitted to ascharpf@pa.gov. (AS 4/21/17)] 03/26/2017 Implemented