Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279759 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification to the local fire department dated 6/13/25 indicates that seven individuals reside in the home. At time of inspection on 12/9/25 it was noted that six individuals reside in the home. The written portion of the notification indicates that three individuals in the home require physical assistance yet the diagram of the home notes only two bedrooms as the exact location of individuals who need assistance evacuating.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. An updated letter was completed by the Residential Director and sent to the fire department which includes information on the location of the bedrooms, and the number of individuals who require assistance with evacuation. Copy attached. Completed 12/17/25 12/17/2025 Implemented
6400.112(c)Documentation of the fire drill completed on 3/24/25 noted an evacuation time of "8:38" for minutes and "4" as seconds. The correct evacuation time of the fire drill could not be discerned from the information recorded.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. The Residential Director retrained staff on how to fill out the fire drill form accurately. Copy attached. Complete 12/19/25 12/19/2025 Implemented
6400.112(e)Documentation of the fire drill completed on 3/24/25 notes that it is a sleep drill that was held at 8:37pm. As outlined in the Regulatory Compliance Guideline (RCG), the sleeping hours required to meet the minimum standard for a sleep drill are 11:00pm to 7:00am unless documentation shows that individuals in the home regularly go to bed at an earlier time. The fire drill was not conducted within the appropriate timeframe.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Director retrained staff on appropriate hours for a sleep drill. Copy attached. Complete 12/19/25 12/19/2025 Implemented
SIN-00263140 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen cabinet door faces and inside of the cabinets had what appeared to be food particles, liquid spills and grease across their surfaces. The upstairs bathroom at the end of the hallway was unsanitary with what appeared to be dust and pieces of debris behind toilet. The baseboard trim surface had a layer of what appeared to be dust.Clean and sanitary conditions shall be maintained in the home. Exterior surfaces of the kitchen cabinets were cleaned on 4/10/25. Photos (4) are attached. The interior of kitchen cabinets was lined with vinyl shelf liner on 4/14/25. Photos (10) are attached. The floor and baseboards in the upstairs bathroom were cleaned on 3/13/25. Photos (4) are attached. 04/14/2025 Implemented
6400.67(a)The carpet in bedroom #1 to the left of the stairs above the kitchen was soiled with multiple stains and darker in high traffic areas.Floors, walls, ceilings and other surfaces shall be in good repair. The carpet in Bedroom #1 was steam cleaned on 3/12/25. The photo is attached. 03/12/2025 Implemented
6400.67(b)In bedroom #2 to the right of the stairs over the kitchen the end cap of the metal baseboard heat was missing exposing the rough edges of the metal housing of the baseboard heat. The curtains in this same bedroom were laying upon the surface of the baseboard heat creating a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The end cap on the radiator in Bedroom #2 was repaired on 3/12/25. The photo is attached. The curtains in Bedroom #2 were removed from the radiator on 3/22/25. The photo is attached. 03/22/2025 Implemented
6400.72(b)The bottom of the screen on the sliding doors in the dining room of the home was pushed out causing the bottom of the screen to be unsecured in the frame creating a open area extending across the bottom. Screens, windows and doors shall be in good repair. The screen was repaired on 3/14/25. The photo is attached. 03/14/2025 Implemented
6400.80(b)At the time of inspection, the tape securing the insulation on the electrical lines extending out of a plastic pipe on the exterior wall and onto the roof of the home was worn away exposing the insulation and visible wires. The area of exposed insulation was at an approximate height of four feet and easily touchable when on the porch. The outside of the home shall be free from unsafe conditions. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The pipes were retaped on 4/11/25. Photo is attached. 04/11/2025 Implemented
6400.82(f)At the time of inspection there were no individual clean paper or cloth towels in the bathroom at the end of the hallway.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Paper Towels were replaced immediately. The photo is attached. 03/11/2025 Implemented
SIN-00242462 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Excessive dryer lint, that when compacted formed a baseball size ball of lint, was found in the lint screen of the second dryer in the laundry drying area. The excessive lint created a fire hazard. The lint was removed at time of inspection. Furniture and equipment shall be nonhazardous, clean and sturdy. On 04/03/2024 the dryer lint screen from all the dryers were cleaned. 04/03/2024 Implemented
6400.45(b)Documentation notes that Staff #1's annual fire safety training was completed on 9/22/22 then not again until 10/10/23, exceeding the annual requirement.A minimum of 1 staff person for every 16 individuals shall be physically present at the home when individuals are sleeping at the home.Staff training procedure regarding mandated training compliance was reviewed by People Operations Director and Training Manager 05/01/2024 Implemented
6400.169(a)Documentation of medication administration training for Staff #1 noted an annual practicum completion date of 12/11/23, with additional documentation noting observations completed on 3/23 and 12/23. Documentation provided illustrates that the observations were not completed at the six-month interval as required.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Medication administration trainers reviewed ODP Medication Administration Remediation Chart and have implemented chart required practices after identifying the issue prior to licensing. Implementation of plan was put in place in March of 2024. The center¿s Quality Management team has begun reviewing all required medication observations for staff, including staff returning from LOA to identify the number of observations and/or MAR reviews needed to rectify deficiencies within a staff members medication recertification. (Attachment 3 Remediation Matrix) 03/31/2024 Implemented
6400.195(c)(4)The restrictive procedure in place for Individual #1 at the time of inspection did not list a target date to achieve the outcome.The behavior support component of the individual plan shall include: A target date to achieve the outcome.After identification of the identified concern, it was noted that the new HER system implemented within all Devereux centers was not correctly pulling all required information into the restrictive procedure plan. The center¿s representative met with the national implementation team to correct the report error for all RPPs within the Pocono Center. All RPPs have been updated within all individual¿s electronic health record. 04/29/2024 Implemented
6400.195(c)(8)The restrictive procedure in place for Individual #1 at the time of inspection did not list the name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan.The behavior support component of the individual plan shall include: The name of the staff person responsible for monitoring and documenting progress with the behavior support component of the individual plan.After identifying the concern, it was noted that the new EHR system implemented within all Devereux centers was not correctly pulling all required information into the restrictive procedure plan. The center¿s representative met with the national implementation team to correct the report error for all RPPs within the Pocono Center. All RPPs have been updated within all individual¿s electronic health record. 04/29/2024 Implemented
SIN-00222534 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a dark ring resembling mildew along the water line in the toilet in the bathroom located off of Individual #1's bedroom. There was also a strong smell of urine in the bathroom.Clean and sanitary conditions shall be maintained in the home. The facilities maintenance manager confirmed the water line on the toilet was clean. The facilities maintenance manager will also recaulk the toilet to reduce potential for odor by 05/05/2023 05/05/2023 Implemented
6400.67(a)A knob was missing from a cabinet located to the left of the dishwasher in the kitchen.Floors, walls, ceilings and other surfaces shall be in good repair. The center¿s Facilities Maintenance team replaced the missing knob from the cabinet located to the left of the dishwasher. (Attachment: Sunny Hill Cabinet Knob) 04/27/2023 Implemented
SIN-00189709 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Fire drills conducted on 5/19/20, 6/19/20, 6/23/20, 7/30/20, 8/24/20, and 9/30/20, exceeded the evacuation time of 5 minutes that was approved by a fire safety expert. These drills do not document problems encountered that impacted the evacuation time.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. The center was aware of drills exceeding maximum allowed time and had created a plan to install a new fire exit to decrease evacuation time. This process was completed and noted a reduction in evacuation time. Fire drill record review processes were also review by the center to ensure review practices could meet and ensure regulatory compliance. 05/31/2021 Implemented
6400.112(d)The residence was inspected by a fire safety expert on 3/4/2020, based on the inspection, an acceptable evacuation time of 5 minutes was approved for the home. For fire drills reviewed from January 2020 through March 2021, multiple drills conducted exceeded the approved 5 minute evacuation time. Fire drill dates and evacuation times as follows: 5/19/20 evacuation time of 8 minutes and 8 seconds, 6/19/20 evacuation time of 9 minutes and 12 seconds, 6/23/20 evacuation time of 8 minutes and 5 seconds, 7/13/20 evacuation time of 17 minutes and 30s, 7/30/20 evacuation time of 9 minutes 10 seconds, 8/24/20 evacuation time of 7 minutes 23 seconds, and 9/30/20 evacuation time of 6 minutes and 30 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The center was aware of drills exceeding maximum allowed time and had created a plan to install a new fire exit to decrease evacuation time. This process was completed and noted a reduction in evacuation time. 05/31/2021 Implemented
6400.112(f)Fire drills reviewed from January 2020 through March 2021 indicated that only the front door exit was being used during drills.. Alternate exits shall be used during the fire drills.Alternate exit routes shall be used during fire drills. Fire drill record review processes were review by the center to ensure review practices could meet and ensure regulatory compliance. 05/31/2021 Implemented
SIN-00111940 Renewal 05/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #1's assessment was not provided to SC/team members 30 days prior to the ISP meeting. It was sent 08/19/16 and the meeting was on 09/07/16.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Clinical Director will review with all specialists the need to utilize tracking systems to ensure all assessments are completed and provided to the SC on time. (Please see attachment 1) This will be reviewed at a clinical meeting prior to 6/30/17. 06/30/2017 Implemented
SIN-00091011 Renewal 04/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The bathroom in the bedroom of Individual #2 and the upstairs bathroom in the spare room have a lock on the outside of the door which would allow for someone to be locked in the bathroom in the event of a fire.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The two locks, one of which was broken and unusable, were both removed on the day of inspection. Regulations regarding the types of locks that can and that cannot be used within the residential homes will be reviewed with all current maintenance staff by May 31st and all new maintenance staff ongoing. All maintenance staff will ensure that proper locks are purchased and maintained in all programs. 05/31/2016 Implemented
6400.195(a)Individual #3 and Individual #4 have a baby monitor in their shared bedroom. Staff interviews indicate that the baby monitor is used to monitor the individuals' activities in their bedroom as they will argue. This restricts their right to privacy in the bedroom.For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures. The use of the baby monitor in the shared bedroom of individual #3 and individual #1 has been removed effective immediately. Supervision checks will be increased during times the two individuals are in the bedroom together to every 15 minutes effective immediately. The increased supervision checks will be communicated to all staff by the Residential Manager through shift report effective immediately. The Program Specialist will ask the Supports Coordinator for a revision to the ISP to reflect this change by May 13, 2016. If continued difficulties occur even with the increase in supervision checks, then a restrictive plan will be considered by the treatment team as an option. The correct interpretation of the use of baby monitors with regard to regulation 195(b) and this being restrictive will be reviewed at the next Clinical Meeting, Manager¿s Meeting and Quality Management Meeting. To be completed by May 31, 2016. 05/31/2016 Implemented
SIN-00070730 Renewal 03/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 is a Program Specialist and does not have First Aid/CPR training.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Program Specialist, MAL, is scheduled and will complete First Aid/CPR training on 4/14/15 and annually. This training will be provided by a credentialed trainer. Proof of completion of this training will be forwarded to BHSL. The Human Resources staff and trainer will ensure that all staff who transfer from a position to another, complete all necessary trainings prior to beginning their new role. Ongoing monitoring of records will be completed by the Human Resources staff to ensure proper documentation is completed. 04/14/2015 Implemented
SIN-00172827 Renewal 03/02/2020 Compliant - Finalized
SIN-00152342 Renewal 03/18/2019 Compliant - Finalized
SIN-00130509 Renewal 03/20/2018 Compliant - Finalized
SIN-00130488 Renewal 03/20/2018 Compliant - Finalized
SIN-00136799 Renewal 03/20/2018 Compliant - Finalized
SIN-00057378 Renewal 01/23/2014 Compliant - Finalized