Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223833 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)There was no fire safety training in the records that showed what curriculum used to train individual 2. 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 individual had fire safety training on January 6, 2023 when it was reviewed with him and signed off. See attachment 26. 01/06/2023 Implemented
6400.213(1)(i)The individual's religion is not noted in the record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's FACE sheet has been updated to reflect that he does not have any affiliation to religion. See attachment 27 06/07/2023 Implemented
SIN-00211257 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Food was discovered uncovered on counter during inspection. Agency staff said it was an individual's lunch, but the individual wasn't eating it at the time. At the end of the inspection, the food left on the counter had insects around it, the staff was made aware and discarded the food in the trash.Clean and sanitary conditions shall be maintained in the home. House manager met with the employees who are assigned to work at 1012-B and reviewed the importance of food safety, and cleanliness of the individuals home. 10/18/2022 Implemented
6400.64(e)There was no lid on the trash receptacle in the kitchen area.Trash receptacles over 18 inches high shall have lids. New trashcan with lid was purchased and placed in the kitchen of the home. 10/24/2022 Implemented
6400.67(a)the Wall in living room area is patched, the bathroom ceiling/wall patched up in multiple places and the towel holder on the wall in the bathroom needs to be repaired as it is not screwed to the wall. The blinds in the bedroom were damaged and need to be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. House coordinator submitted a work order through maintenance to have the bathroom ceiling/wall patched up and work order to have towel holder repaired. Request of purchase of blinds and blinds installed was put in the work order system as well. 11/25/2022 Implemented
6400.46(a)The Agency Staff was not trained on the use of the fire alarm during the on site inspection process. Staff on duty had to call a manager to walk through the entire process.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.All employees at PAHrtners that do not know how to operate a fire drill, will be trained in the next coming days to ensure trained. PAHrtners will ensure all current hires are trained by November 25th. 11/25/2022 Implemented
SIN-00186236 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The Venetian blinds in Individual 1's bedroom were damaged. Several separate segments of the blinds were cracked or broken off.Floors, walls, ceilings and other surfaces shall be in good repair. Provider purchased new blinds to replace the ones that were damaged. Blinds have been installed in individual's bedroom. 04/27/2021 Implemented
6400.104There were three areas of concern relating to the notification to the local fire department, a letter dated 07/10/2020: First, Individual 1's Individual Support Plan (ISP) dated 03/24/2021 notes that "[Individual 1] NEEDS PROMPTING TO GET OUT OF THE HOME WHEN THE ALARM IS GOING OFF. A STAFF WOULD NEED TO ACCOMPANY [the individual] DURING A FIRE DRILL TO ENSURE THAT [the individual] DOES NOT RUN OFF WHILE THEY ARE OUTSIDE." As such, the letter must include information on the location of Individual 1's bedroom within the site and the assistance they requires to evacuate safely. Second, Individual 1's address is not up to date in the latest issuance of the letter; the individual is listed as living at a previous address. Third, the notification to the local fire department did not receive the letter, it was addressed to an Emergency Management Administrator at the county's police department.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Provider contacted the Fire Department to get the updated and correct contact information to send fire letters to. PAHrtners updated the entire fire letter to include exact location of the bedroom and the type of assistance the individual needs with evacuating in event of an actual fire. 05/18/2021 Implemented
6400.111(e)The site's only available fire extinguisher---located in the kitchen area---was inaccessible to staff and individuals. The extinguisher was secured within a locked box with a tempered glass pane, and there was hammer attached to the box by a chain. Fire extinguishers must be accessible to staff and individuals at all times, not only during emergencies. A fire extinguisher shall be accessible to staff persons and individuals. Day of licensing inspection, the glass panel was removed from the fire extinguisher to be accessible to staff and individuals. 04/13/2021 Implemented
SIN-00158883 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill held for this home during the month of January 2019. An unannounced fire drill shall be held at least once a month. A designated person (Denise D'Antonio) will audit every month during the week of 15th to ensure fire drill forms are turned in, and completed. In the event fire drills were not completed, Denise will inform the Operations Director who in turn will ensure fire drills are completed by the team. This is effective August 1, 2019. 08/31/2019 Implemented
SIN-00132606 Renewal 04/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was mildew found in the lower corner of the shower stall.Clean and sanitary conditions shall be maintained in the home. The mildew has been cleaned. The previous caulk strip was removed and the area was scrubbed. New caulk was added. 05/07/2018 Implemented
6400.141(c)(7)Individual #1's last GYN exam was held on 10/18/16.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. Her GYN was scheduled for 1/22/18 and the doctor's office indicated that Medicare would not cover until 10/18/18. 05/15/2018 Implemented
6400.185(a)Individual #'1's annual ISP was not implemented by the start date of 12/24/17. The ISP shall be implemented by the ISP's start date. The Program Specialist reviewed all ISP and revised the ISP outcomes to reflect the start date as 12/24/17 and with this correct date, the ISP dates were corrected to reflect the annual ISP start date. 04/09/2018 Implemented
6400.186(a)Individual 31's 90 day ISP reviews were not coordinated every three months with the annual date of 12/24/17.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. Individual's ISP Review dates were revised to reflect the annual date of 12/24/17. Her last ISP review was 3/13/18. We revised it by having one from 3/13/18 to 4/24/18 and then the next one would be on June 24, 2018. 04/16/2018 Implemented
SIN-00258392 Renewal 01/09/2025 Compliant - Finalized
SIN-00113969 Renewal 03/13/2017 Compliant - Finalized