Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00273405 Renewal 09/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1 annual physical dated 6.20.25 did not document that a vision or hearing screening was completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. On 9/10/25, staff contacted the PCP that completed the physical initially and secured a follow up on 10/7/25 to have the sections not meeting compliance corrected as they were completed the date of the physical. 09/11/2025 Implemented
6400.151(a)Staff shall have a physical exam 12 months prior to employment. Staff #1 date of hire was 7.28.25. Staff #1 did not have a physical at the time of inspection. 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. On 9/9/25 during inspection, this staff's physical was and had been on file, but not presented to the licensing team. The date of the physical is 7/10/25 as she was a new staff and not allowed into orientation without it. 11/01/2025 Implemented
6400.151(c)(2)Staff shall have a physical exam prior to employment and the physical shall include a TB skin test with negative results. Staff #1 did not have a TB test completed prior to employment. 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. On 9/9/25 during inspection, this staff's physical was and had been on file, but not presented to the licensing team. The date of the physical is 7/10/25 as she was a new staff and not allowed into orientation without it. The TB test was part of this physical. 11/01/2025 Implemented
SIN-00231090 Renewal 09/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1 did not have a physical as required. 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. On 9/27/23, Staff #1 completed his annual physical. 09/27/2023 Implemented
6400.52(c)(1)Review of training files for Staff #1 indicated that there was no documentation to support that they had received training on the required components of Person Centered practices and supporting individuals to develop and maintain relationships during the 7/1/22 to 6/30/23 training year as required.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.On 8/10/23, Staff # 1 received training on Person-Centered practices and supporting individuals to develop and maintain relationships. 08/10/2023 Implemented
6400.52(c)(2)There was no documentation to support that Staff #1 had annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101--- during the 7/1/22 to 6/30/23 training year as required.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.On 8/10/23, Staff # 1 received annual training in the prevention, detection and reporting of abuse, suspected abuse, and alleged abuse. 08/10/2023 Implemented
SIN-00160740 Renewal 09/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathtub and faucet were dirty with a film and soap scumClean and sanitary conditions shall be maintained in the home. The bathrooms were cleaned immediately. The Residential Supervisor will continue to make regular visits to the residence in order to ensure physical plant cleanliness complies with licensing standards. The Senior house staff will continue to complete daily cleanliness checks. Moving forward our senior staff will regularly assign all shifts to clean the bathrooms and other areas of the home on a regular basis. 10/04/2019 Implemented
6400.67(a)The entire bathtub in the hallway bathroom is chipped and worn to the point that it is actually discolored.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance refinished the tub and tiles. The Residential Supervisor will continue to make regular visits to the residence in order to ensure physical plant complies with licensing standards. The Senior house staff will continue to complete daily safety checks in the home and will notify the Regional Director or Residential Supervisor if there are any maintenance concerns. If there is a maintenance issue the staff will submit maintenance requests in our electronic database. 10/11/2019 Implemented
SIN-00101244 Renewal 09/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Staff #1 had 20.5 hours of training in the 2015-2016 training year. He was 3.5 hours short of the required 24 hours of annual training.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. 46 (d) During the licensing review on 9/7 and 9/8/16, the Program Specialist completed 24 hours of training but did not have the training documentation in his employee file. Attach are copies of the total training hours as well as a signing sheet verifying fire safety training (attachment d). The Deputy CEO will ensure that each employee receives a total of 24 hours per 6400 Regulation. The HR/Training Coordinator will use a tracking sheet by 11/1/16 to monitor when employees are due for training and what training subjects, per ODP Regulations they are required to take. Additionally, the immediate supervisors will receive monthly updates on training hours once their employees (attachment c) 11/01/2016 Implemented
6400.186(c)(2)Reviews of ISP areas such as health and safety are not being completed in the ISP Reviews for Individual #2. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. The Program Specialist will be trained by the Deputy CEO regulatory and best practice standards in completing all areas on the ISP by 10/31/16. The Program Specialist will review all sections on the ISP and ensure that it is completed accurately. Additionally, the Program Specialist will follow up with the Supports Coordinator via email and/or agency letter to make sure all the necessary corrections are made and updated. 10/31/2016 Implemented
SIN-00209401 Unannounced Monitoring 07/13/2022 Compliant - Finalized
SIN-00056879 Initial review 10/22/2013 Compliant - Finalized