Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261116 Renewal 01/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)Lorazepam 0.5mg PRN ordered for severe anxiety and self-harm behaviors for Individual One was discontinued on 12/17 "per ODP demand". This medication was administered 12/1 for self-harm behaviors.A prescription order shall be kept current.The agency¿s policy on the use of PRN psychotropic medications is being reviewed by the Compliance Department. The policy has been updated to include the procedure for determining the prescribing a PRN medication and for approving the administration of a PRN medication per Bulletin 00-02-09. The policy is scheduled to be reviewed by March 21, 2025. Upon approval, this policy will be used as the basis for use of PRN psychotropic medications. 03/08/2025 Implemented
SIN-00243490 Unannounced Monitoring 04/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(g)Two of the three bed shakers in the home were not functioning when the fire alarm was set off. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. 1.a. Maintenance was contacted on 4/26/24 upon discovery of the non-functional bedshaker. The bedshaker was fixed the same day. 04/26/2024 Implemented
6400.165(b)The PRN Triple Antibiotic Ointment prescribed to individual #3 was not present in her medication box. This is a repeat violation.A prescription order shall be kept current.2.a. The PRN Triple Antibiotic Ointment was ordered on 4/26/24 and delivered to the house on 4/29/24. 04/29/2024 Implemented
SIN-00211260 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Staff onsite was not trained on how to sound the alarm. The staff had to contact a manager to walk her through the process. The Staff person at the home did not have knowledge on how to use the fire alarm and a drill could not be conducted under normal staffing conditions.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-00207339 Renewal 04/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)10 of the 11 self-assessments completed were not completed 3-6 months prior to the license expiration date or 3-6 months after the last inspection 4/21The 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. Provider created a self inspection spreadsheet with due dates in the folder with the spreadsheet includes completed self inspection forms with the right forms to use. 07/15/2022 Implemented
6400.112(a)There was No fire drill record for 12/2021. An unannounced fire drill shall be held at least once a month. Provider developed a visual step by step policy for residential managers to follow on how to properly conduct monthly fire drills. 07/18/2022 Implemented
6400.24Salisbury Behavioral Health is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1s record to establish that the staff had been a resident of the state of Pennsylvania for two or more years prior to their date of hire on 02/27/2022. An application for a Federal Bureau of Investigation (FBI) criminal history record check was not submitted for this staff within 5 working days of their date of hire.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Provider corrected the application in workday to add that the staff has been a resident of the state of PA for two or more years prior to their date of hire. 04/13/2022 Implemented
SIN-00186238 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Spray bottle cleaners were located in the laundry room outside of the cleaning cabinet at the time of review. The cleaning cabinet and spray cleaners was accessible to individuals only while doing laundryPoisonous materials shall be kept locked or made inaccessible to individuals. Provider purchased a new lock for the assigned cabinet in the laundry room for all cleaning supplies to be locked up in cabinet. 05/13/2021 Implemented
6400.81(k)(6)No Mirror was found in individual 1's temporary bedroom.In bedrooms, each individual shall have the following: A mirror. Provider purchased a new mirror for the individual's bedroom. 05/13/2021 Implemented