Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243039 Renewal 04/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)For the following new hire staff, their documentation states that they did live outside of the state in the last two years, however no FBI background checks were completed. Staff #1 Staff #2 Staff #3 Staff #4 Staff#5 The following new hires did not check off if they lived out of state within last two years and have no FBI check: Staff #6 Staff #7 Staff #8If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. On 5/9/24 the HR Onboarding Specialist began submission requests for FBI clearances for staff #1-5 and began working with staff #6-8 to correct their documentation and, if necessary, submit requests for FBI clearances. Documentation of this information will be maintained in staff HR files. 05/31/2024 Implemented
6400.64(a)There are open bins of bagged garbage in the garage.Clean and sanitary conditions shall be maintained in the home. On 4/10/24 the open bins of bagged garbage were removed from the garage. The Residential Supervisor will conduct training with group home staff and Lead DSPs on the proper disposal of garbage. Training will be completed by 5/31/24. Documentation will be maintained in staff HR files. 05/31/2024 Implemented
6400.67(a)The set of drawers next to the stove have broken drawer fronts, and the drawers themselves are off track/stuck. There is a wooden floor panel in the laundry room that is weak and bows when stepped on. This should be replaced to ensure safety.Floors, walls, ceilings and other surfaces shall be in good repair. On 5/8/24 the floor panel in the laundry room and the kitchen cabinet were replaced by maintenance staff. Beginning May 2024 the Residential Supervisor will complete a monthly site monitoring form. This form will be sent to the Associate Director for review. Issue noted will be sent to the Manager of Facilities for follow up. 05/08/2024 Implemented
6400.110(a)The garage's smoke detector doesn't work. The attic doesn't have a smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. On 4/12/24 a new smoke detector was placed in the garage. On 4/10/24 the Manager of Facilities verified that a smoke detector was present in the attic and was in working order. Smoke detectors will continue to be tested weekly by the Lead DSP. Beginning May 2024 the Residential Supervisor will complete a monthly site monitoring form. This form will be sent to the Associate Director for review. Issue noted will be sent to the Manager of Facilities for follow up. 05/10/2024 Implemented
6400.111(a)The attic doesn't have a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. On 4/10/24 a fire extinguisher was placed in the attic. On 4/10/24 the Manager of Facilities verified that there was a working fire extinguisher in the garage directly below the attic. 05/10/2024 Implemented
SIN-00082047 Unannounced Monitoring 08/04/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 had a rash beginning in March of 2015. Nursing Staff #1 felt Individual #1 needed a dermatology appointment and thought it had been scheduled. Staff #1 went on leave from April to July of 2015. Upon return, Staff #1 realized this appointment did not occur. Staff #1 scheduled an appointment for 7/21/15. At this appointment, Individual #1 was diagnosed with Scabies. Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All medical appointments for Individual #1 were scheduled and kept based on recommendations from the PCP. The following is a timeline of appointments, treatments, and recommendations for Individual #1. On April 4, 2015 Individual #1 was seen by the PCP, diagnosed with Seborrhea, treatment recommended (Nizoral cream), and the PCP indicated that a Dermatology appointment scheduled for 5/4/15 was not needed and was cancelled. On April 30, 2015 Individual #1 had a follow up appointment with the PCP and at that time treatment was continued (Nizoral cream). On June 22, 2015 Individual #1 was seen by the PCP for an annual physical. At this visit the PCP recommended and scheduled a Dermatology consult to take place 7/21/15. At the July 21, 2015 consult Individual #1 was diagnosed with Scabies, treatment was recommended (Permethrin cream), and a follow up appointment was scheduled for 8/18/15. In addition, staff will be retrained on appropriate documentation and reporting of a medical concern. The training will be conducted by the Program Specialist and wil focus on utilization of the Change of Health/Accident Report and weekly monitoring of medical concerns. Training will be completed by 8/28/15. Nursing staff will be retrained in appropriate documentation of medical concerns. The training will be completed by the Manager of Health Services. The focus of the retraining will be on the documentation and monitoring of medical concerns as well as Nursing staff review of Change of Health/Accident forms and assessment, documentation, and monitoring of medical concerns.This training will be completed by 8/20/15. (The home supervisor is responsible to report any medical concerns/appointments to the program specialist immediately. The program specailist is responsible to report those concerns/appointments to the nursing staff within 1 hour of being notified. The nursing staff will ensure that all medical concerns and appointments are followed up with in a timely manner. Documentation of the notification to all relevenat staff members will kept. AH 9.18.15) 08/28/2015 Implemented
SIN-00067517 Renewal 09/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff D's most recent Medication Administration Practicum was completed on 8/18/13.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. The medication trainer was retrained by the Human Resources Manager on 9/30/14 to ensure that documentation of staff medication testing, trainings and observations are correctly and properly written on all forms and to ensure that staff names and dates are clearly written and accurate on all forms as the paperwork was missing the staff identifiers on some pages. See attached training sheet. The trainer will monitor all recall dates to ensure all staff are in compliance. The Human Resources Manager will monitor quarterly. 09/30/2014 Implemented
SIN-00158971 Renewal 07/18/2019 Compliant - Finalized