Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292412 Renewal 07/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The last notification letter sent to the fire department was dated 8/22/2025 and had two individuals listed on it. However, on May 4th, 2026, this home became a one-person home, and a new notification letter was not sent. According to this regulation, the fire department notification letter must be kept current.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. Residential currently has informal procedures to manage the notification letters. This letter was updated and sent when discovered on 8/4/2026. 08/20/2026 Implemented
SIN-00293678 Unannounced Monitoring 06/10/2026 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On April 9, 2024, Individual #1 was evaluated by ENT Physician who performed a Fluoroscopy exam. The findings of the exam were that Individual #1 is experiencing penetration and mild aspiration. The Individual was referred to Speech Pathology at the time. Speech Pathology began on 6/27/24 and ended 7/11/2024 after 3 appointments due to self-discharge. At the time of discharge from Speech Pathology, Individual #1 was advised to continue with swallow exercises and follow safe/eating drinking recommendations. On May 8, 2024, Alexander Spring Family Care updated Individual #1's medical history to list an active diagnosis of dysphagia. On 3/7/2026 Staff #1 wrote in their daily notes that they gave Individual #1 a softened microwaved meal. Individual #1 choked twice and ran to the restroom. Upon returning, Staff #1 reported that they had blended the meal for the Individual, which they tried to eat, but could not continue. On 4/25/2026, Staff reported in their daily notes that in the evening (sometime before 10:30pm) Individual #1 complained of something in their throat. On 4/26/2026 at 6:00am, Staff reported in their daily notes that Individual #1 again complained of something feeling caught in their throat. Individual #1 then refused to eat their offered breakfast. At 11:10am, Staff called 911 due to the Individuals feeling of something caught in their throat. Hospital records from admittance on 4/26/2026 state that the staff who accompanied Individual #1 to the hospital (Staff #1) reported that there have been chronic issues ongoing at the group home with swallowing and choking events. On 5/4/2026 Individual #1 succumbed to their symptoms and passed away at UPMC Carlisle. Individual #1's death certificate indicates their immediate cause of death was Aspiration Pneumonia combined with septic shock, esophageal obstruction, and food impaction. · Failure to provide care as instructed by a health care professional. Upon discharge from Speech Pathology on 7/11/2024, there is no evidence provided to the Department that Individual #1 was following the recommendation of practicing swallowing exercises. Upon discussion with staff members, they also reported that they had not witnessed Individual #1 practicing swallowing exercises, as recommended by the physician. · Failure to provide needed care and/or neglect. Staff #1 logged in Individual #1's daily notes on 3/7/2026 that they experienced a choking incident upon attempting to eat a microwaved meal. Individual #1 reportedly choked twice, then ran to the restroom. Upon returning, Staff #1 reported that they blended the meal for an additional attempt for Individual #1 to eat it, which they could not. Additionally, per hospital records, staff reported that Individual #1 has been experiencing chronic issues with swallowing and choking events. From the time of Individual #1's discharge from Speech Pathology on 7/11/2024 until 4/26/2026 (hospital admittance), Individual #1 did not have any follow-up swallow assessments completed although they had reportedly experienced choking incidents, per staff documentation and reports. Individual #1 had several written protocols due to their increased risk of respiratory infections and pneumonias, and risk of aspiration. Staff #1 worked with Individual #1 on 4/25/2026 from 10:00am -- 8:30pm, then again on 4/26/2026 from 11:00am -- 7:00pm. Staff #2 worked with Individual #1 on 4/25/2026 from 8:00pm until 4/26/2026 at 11:00am. Staff #1 acknowledged that they received training on Individual #1 being an increased risk of aspiration, constipation, dehydration and pressure sores (Fatal Five) as well as dysphagia on 5/21/2025. Staff #2 acknowledge that they received this same training on 2/6/2026. Department of Human Services training on Fatal Five identifies signs and symptoms of aspiration include statements such as "food is getting stuck." Per Individual #1's daily service notes from 4/25/2026 from sometime prior to 10:30pm until 4/26/2026 at 11:10am (when staff called 911), Individual #1 had reported at least 3 times that they had the feeling of something stuck in their throat. Additionally, Individual #1 refused breakfast on 4/26/2026 due to the feeling of something stuck in their throat. Individual #1 is diagnosed with Prader-Willi Syndrome which is defined as a rare genetic disorder that affects a part of the brain that regulates hunger and satiety (feeling full). Due to Individual #1's diagnosis, their home was equipped with locking cabinets and refrigerator to limit access to food. Because the condition is associated with a persistent and intense drive to eat, a sudden refusal of food would be abnormal and should raise concern for an underlying medical problem requiring prompt assessment. Staff failed to recognize the refusal of food as being an adequate concern as well as failing to recognize that they were experiencing signs of aspiration with the multiple statements made stating that food felt stuck in their throat for over 12 hours.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Residential currently has a policy to call 911 if someone is choking. Because this individual was still breathing and able to speak, 911 was not initially called. It was after he refused to eat and continued to say he felt like something was stuck in his throat that he was given medical care. Through a review of the records it shows that the individual had previously received treatment for swallowing difficulties and had been recommended to complete exercises that he was not completing. 09/18/2026 Accepted
6400.181(d)Individual #1's most recent assessment has multiple dates on the document that are contradicting. The cover sheet for the assessment states that it was sent on 9/19/2025 for the review period of 9/18/2024 -- 9/18/2025. The date listed at the top of the assessment is written as 9/6/2024. Page 14 of the assessment is signed by Individual #1 with a typed date beside their name of 9/19/2024. The program specialist's name is typed with a date beside their name of 9/19/2024. The date that the assessment was sent to the team is listed as 1/7/2026 with the residential secretary's initials. Page 13 of the lifetime medical history is dated 9/19/2025 by the program specialist's signature.The program specialist shall sign and date the assessment. Residential currently trains Program Specialists to complete assessments by showing them examples of completed assessments and reviewing the sections of the assessment reviewing what information should be included. The assessment reviewed did not contain Program Specialist signature. 08/20/2026 Accepted
6400.181(e)(10)Individual #1 attended speech pathology from 6/27/2024 -- 7/11/2024. Upon discharge from speech pathology, Individual #1 was recommended to continue with swallow exercises at home and follow safe eating/drinking practices. Individual #1's lifetime medical history updated on 9/18/2025 and included in their current assessment does not include information regarding speech pathology attendance and discharge or recommendation for swallow exercises.The assessment must include the following information: A lifetime medical history. Residential currently trains Program Specialists to complete assessments by showing them examples of completed assessments and reviewing the sections of the assessment reviewing what information should be included. The assessments reviewed did not contain accurate information related to lifetime medical history. 08/20/2026 Accepted
6400.52(c)(6)Individual #1 has the following specialized plans and protocols: Restrictive (food locked and administered as appropriate), SEEN plan, fall protocol, Fatal Five protocol, dental plan, cardiac care protocol, swallow protocol, diabetes protocol, defibrillator protocol. All plans/protocols list the trainer as "written plan" or "written protocol". The person-specific training was not trained by an actual trainer and in-person, as required.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Residential currently trains staff on individual protocols and has the staff sign off on the protocol. While the training is done in person, a staff signature or verification was not noted on the plan. 08/20/2026 Accepted
SIN-00253686 Unannounced Monitoring 10/16/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)The Individual Inventory sheet for individual #1 dated 8/2/24 lists "Lawn Mower Set (lawn mower, 3 batteries, 2 chargers, weed whacker and leaf blower)" with date purchased as 2023 and estimated value of $2335.00. There is mention of individual #1 enjoying lawn care in their ISP but no mention of wanting to purchase the lawn care equipment. With a purchase this large and the item(s) being something the provider is generally responsible for; it should be documented in the ISP to clarify that this is not a misuse of their personal funds.Individual funds and property shall be used for the individual's benefit. An Addendum to the individual's ISP was submitted and approved by County. The Addendum clearly states that CPARC has a mower on the property but the individual prefers to purchase and use his own electric mower and yard appliances when mowing. It was approved in his ISP on 10/17/24. 10/17/2024 Accepted
SIN-00247594 Renewal 07/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessment began and ended on 7/2/2024. 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-00227711 Unannounced Monitoring 07/11/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)There is no strobe in the bathroom. A resident is legally deaf and utilizes a cochlear implant. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. We have contacted Brinks to install a strobe light in both bathrooms, not just the one cited. They were checking to see if they need a permit. Heard from Brinks and they do not need a permit for Hamilton St.; We should be receiving the agreement to install two strobe lights and a power supply. Once the agreement is returned to them the installation will be scheduled. Brinks estimates 2-3 weeks for install but could be more or less so I chose the 8/31/23 date to cover if later versus sooner (we will also need a power supply installed). Attachment 5. 08/31/2023 Accepted
6400.112(c)The 07/05/23 fire drill does not indicate the exit used.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. Prior to this licensing review, we had one upper management staff review the monthly fire drills from all programs. We have added a second reviewer line so that 2 upper management staff will review the fire drill document to ensure all areas are complete. This will be implemented with the August fire drills. Attachment 6. 08/01/2023 Accepted
SIN-00210617 Unannounced Monitoring 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)The current assessment for Individual #1 was not in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The provider shall follow all previous aspects of the prior plan of correction plus add a weekly check from senior management. Senior management must sign off that they were in the home and had reviewed the assessment on site. 09/12/2022 Implemented
SIN-00151553 Renewal 04/30/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(a)Individual #1 is prescribed Calcium with Vitamin D3 powder ½ tsp daily. Physician's order on the OTC form states ½ tsp daily. Bottle states ½ tsp daily. Powder is administered by staff by sprinkling on food, but no documentation was present from the physician stating how the powder is to be administered. Individual #1 is prescribed Lactobacillus Duo. There was no pharmaceutical label on the bottle. MAR states take one capsule daily, sprinkle entire contents on small amount of food. OTC form documents the physicians order as 1 capsule once daily, directions on the original OTC bottle label state 1-2 capsules daily, or as directed.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The referenced medications of this cite are purchased by the individual¿s mother on-line and do not come with a label. The pharmacy will not provide a label, even with a doctor¿s script. After a conversation with Dr. Neiderer, the individual¿s doctor, he wrote two scripts for the medications on May 14, 2019 that reflects the directions on the medications. The directions on the bottle, the script, the Medication List, and the MAR are now identical to each other. Additionally, the medications are being maintained in a plastic bag, with a copy of the doctor¿s script, to remove any potential doubt regarding administration of the two medications. It is the responsibility of the Program Supervisor to ensure that all medications are properly labeled and/or have a doctor¿s letter to accompany the medication should a script not be available. The Program Specialist is to perform oversight and review medications at least once monthly. Attachment 4B 05/14/2019 Implemented
6400.163(c)Individual #1 attended a psychiatric medication review on 5/18/18 and not again until 10/17/18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.On May 8th, 9th and 10th, 2019 the staff at the Hamilton Group Home were retrained on the proper procedure/timing for 3-month medication review appointments for when a medication is prescribed for a diagnosed psychiatric illness. The applicable forms were reviewed to ensure staff knew what documentation is necessary. The `Appointments¿ log was reviewed. The Log is where appointment schedule dates are noted; the attending staff initial when the appointment is successfully completed and the next appointment, if known at that time, is noted. It is the responsibility of the Program Supervisor to ensure the appointments are up to date and the responsibility of the Program Specialist to review the Log for thoroughness and completeness. Attachment #4A 05/08/2019 Implemented
SIN-00216116 Unannounced Monitoring 12/09/2022 Compliant - Finalized
SIN-00212259 Unannounced Monitoring 09/30/2022 Compliant - Finalized
SIN-00201211 Unannounced Monitoring 03/02/2022 Compliant - Finalized
SIN-00107739 Renewal 04/04/2017 Compliant - Finalized
SIN-00092441 Renewal 04/05/2016 Compliant - Finalized