Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275548 Renewal 10/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(3)Individual #1is not current with immunizations as recommended by the Center for Disease Control. Individual #1 has not had a TDAP/Tetanus booster since 6/22/15.Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 received her TDAP vaccine on 10/17/25. Documentation attached. 10/30/2025 Implemented
6500.48(b)(6)Staff #1 did not complete annual Individual Service Plan Training.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.The host family has been trained on the ISP. Complete 10/27/25. Copy attached. 10/27/2025 Implemented
6500.135(f)Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 did not have 3-month reviews of these medications complete. Individual #1 had a review completed on 10/14/24 and did not have another review completed until 2/3/25.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Review of psych appts since 2/3 indicates they have been completed timely. Documentation attached. 10/27/2025 Implemented
6500.139(d)Staff #1 did not complete medication administration training as required. Staff #1 completed medication administration training on 9/26/23 and did not complete it again until 10/12/25.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The host family has been retrained on the requirement for medication administration training. Copy attached. 10/27/2025 Implemented
SIN-00253412 Renewal 10/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.64(a)At the time of the inspection, there was a storage room located next to an individual's bedroom on the lower level of the home. There was a large amount of small brown pellets resembling dry pet food scattered all over the visible floor area. There was a strong smell of urine on the lower level of the home at the time of inspection.Clean conditions shall be maintained in all areas of the home.The large amount of brown pellets were cleaned up and a photo was taken and sent to the LifeSharing Coordinator on 11/20/2024. The QI Director and the Life Sharing Coordinator met with the host family on 11/21/2024 to discuss the odor and provide retraining on maintaining clean and sanitary conditions. 11/21/2024 Implemented
6500.109(d)Fire drill evacuation times are not being recorded accurately. The home conducts a fire drill every six months, and all four drills held from January 2023 to the present (1/08/23, 7/08/23, 1/05/24 and 7/04/24) have a recorded evacuation time of "2 min." Documentation for fire drill records should be exact, not approximate or estimated, and include the minutes and seconds.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 smoke detector was operative.The host family had a fire drill on 11/18/24 and recorded the exact evacuation time in minutes and seconds. Documentation of the date and time of the evacuation was sent to the LifeSharing Coordinator. 11/18/2024 Implemented
SIN-00214365 Renewal 10/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(a)The physical provided for Individual #1 was dated 11/6/2020. There was no annual physical provided for the year 2021 or for the year 2022. The physicals shall be completed every year.An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter.Life Share coordinator reviewed approved documents with the provider to ensure they were aware of and began utilizing the proper documentation. 12/13/2023 Implemented
6500.121(c)(7)There was documentation provided reflecting the individual #1 had a gynecology exam on 6/21/2021. There was no appointment in 2022. An appointment was scheduled for 8/19/22 and later rescheduled to 11/14/22. Regardless of the rescheduling, the initial follow update was outside of the annual compliance. The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.The center has implemented an appointment reminder letter that is sent to all providers that reminds the providers of dates for all upcoming routine appointments needed for the calendar year. The specialist will remind the provider of upcoming appointments also during bi-monthly visits to ensure the appointment occurs within the required timeframe. 11/15/2022 Implemented
6500.151(e)(4)Individual #1 annual assessment dated 2/10/2022 was missing the following items: The individual's need for supervisionThe assessment must include the following information: The individual's need for supervision.Amendment has been made to the individual¿s current assessment to reflect the individual¿s supervision needs. 12/09/2022 Implemented
6500.135(g)Individual #1 is prescribed medications to treat symptoms of a psychiatric illness which require medication reviews every 3 months. The only reviews provided at the time of inspection were dated 9/28/21; 12/6/21; 3/8/22 and 6/16/22. This still does not reflect compliance of medication reviews every three months up to the time of inspection.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.Noted reviews did not occur due to staff shortages at the contracts psychiatrist's office. Psychiatrist¿s offices provided a letter noting the reason for cancellation, and the center began working with the contracted psychiatric office to identify a new psychiatrist to reduce/eliminate the possibility of a cancelled appointment. 10/30/2022 Implemented
SIN-00193316 Renewal 09/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.32(r)(4)Individual #1 does have a lock on her bedroom door, however, the lock is considered a "pin" lock and the locking mechanism does not provide easy and immediate access by the individual or staff in the event of an emergency.An individual has the right to lock the individual's bedroom door. The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Provider to remove pin style lock and replaced with keyed locking mechanisms by 10/30/21. 10/30/2021 Implemented
6500.48(b)(2)Staff #1 did not receive training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse during the 2020 training yearThe annual training hours specified in subsection (a) 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.Provider will complete the required APS & OAPS trainings by 10/30/2021. 10/30/2021 Implemented
6500.48(b)(4)Staff #1 did not receive training on recognizing and reporting incidents during the 2020 training year.The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents.Provider will complete required training by 10/30/21. 10/30/2021 Implemented
6500.48(b)(5)Staff # 1 did not receive training on the safe and appropriate use of behavior supports during the 2020 training year.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.Provider reviewed and signed off on the desensitization plan on 10/12/2021. 10/12/2021 Implemented
6500.136(a)(2)The Medication administration record for Individual # 1 does not include the name of the prescribing physician.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The program¿s nursing department has reviewed all MARs vs. current prescriptions to ensure physician medication orders are being correctly documented. 10/08/2021 Implemented
6500.156Individual #1's ISP and annual assessment do not indicate that the individual is able to safely carry any amount of cash on her person. Individual #1 was given "misc spending" ranging from $10.00 to $15.00 on the following dates: 3/31/21, 4/5/21, 5/3/21, 5/10/21, 5/17/21, 5/24/21, 6/1/21, and 6/7/21.The home and the agency shall implement the individual plan, including revisions.Program Specialist requested ISP update to reflect assessment information regarding money management on 10/13/21. 10/30/2021 Implemented
SIN-00179464 Renewal 11/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(4)Individual #1's last vision screening was completed on November 11, 2019. There has been no annual appointment completed or scheduled for 2020. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.On-going FLP¿s will ensure individuals medical appointments are scheduled within the timeframe mandated through 6500 regulations or by medical professional recommendations for follow-up. During the COVID-10 pandemic Devereux will continue to use the Level of Community Transmission information provided by ODP in conjunction with CDC guidance to make informed choices about protecting the health and safety of individuals and staff as well as their families. In the event routine appointments must be postponed due to Covid-19, all attempts to reschedule appointments will be made when community transmission has decreased to levels the minimize risk for the individual. All cancelled appointments will be documented in the individual file with the reason for cancellation and rescheduled date, if applicable. 12/04/2020 Implemented
6500.121(c)(6)Individual #1's tuberculin test was past due. Individual 1's previous tuberculin test was completed on July 15, 2018. Individual #1's most recent tuberculin test was competed Nov 11, 2020.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.On-going FLP¿s will ensure individuals medical appointments are scheduled within the timeframe mandated through 6500 regulations or by medical professional recommendations for follow-up. During the COVID-10 pandemic Devereux will continue to use the Level of Community Transmission information provided by ODP in conjunction with CDC guidance to make informed choices about protecting the health and safety of individuals and staff as well as their families. In the event routine appointments must be postponed due to Covid-19, all attempts to reschedule appointments will be made when community transmission has decreased to levels the minimize risk for the individual. All cancelled appointments will be documented in the individual file with the reason for cancellation and rescheduled date, if applicable. 12/04/2020 Implemented
6500.121(c)(7)Individual# 1's last scheduled gynecological appointment was on April 8, 2019. Visit was not able to be conducted due to individual not cooperating. A desensitization plan was developed to address the Individual's anxiety. To date a new appointment has not been scheduled. The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.On-going FLP¿s will ensure individuals medical appointments are scheduled within the timeframe mandated through 6500 regulations or by medical professional recommendations for follow-up. During the COVID-10 pandemic Devereux will continue to use the Level of Community Transmission information provided by ODP in conjunction with CDC guidance to make informed choices about protecting the health and safety of individuals and staff as well as their families. In the event routine appointments must be postponed due to Covid-19, all attempts to reschedule appointments will be made when community transmission has decreased to levels the minimize risk for the individual. All cancelled appointments will be documented in the individual file with the reason for cancellation and rescheduled date, if applicable. 12/04/2020 Implemented
6500.122(a)Individual #1's dental exam is past due. Individual #1's most recent dental exam was on July 10, 2019. There has been no new appointment scheduled.An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually.On-going FLP¿s will ensure individuals medical appointments are scheduled within the timeframe mandated through 6500 regulations or by medical professional recommendations for follow-up. During the COVID-10 pandemic Devereux will continue to use the Level of Community Transmission information provided by ODP in conjunction with CDC guidance to make informed choices about protecting the health and safety of individuals and staff as well as their families. In the event routine appointments must be postponed due to Covid-19, all attempts to reschedule appointments will be made when community transmission has decreased to levels the minimize risk for the individual. All cancelled appointments will be documented in the individual file with the reason for cancellation and rescheduled date, if applicable. 12/04/2020 Implemented
6500.32(r)(5)The primary caregiver did not have a key for the lock on the Individual #1's bedroom door.An individual has the right to lock the individual's bedroom door. The primary caregiver shall have the key or entry device to lock and unlock the door.To ensure the individuals rights are met Devereux FLSs will consult with each individual regarding their desire to have a lock on their bedroom door. Documentation of the consultation will be documented and place in the individual¿s file and submitted to the individual¿s supports coordinator for input into the individual¿s ISP. If the individual chooses to have a lock on their bedroom door a keyed locking door knob will be installed. A key will be given to the individual and provider. The provider will keep the key stored in an accessible area at all times. Spot audits will be conducted to ensure the provider¿s key is accessible at all times. (Attachment #2: Documentation of individual¿s request form) 01/01/2021 Implemented
SIN-00121516 Renewal 08/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(6)Individual #1 had a TB test on 12-09-13, then not again until 07-13-16.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.The system for tracking physical requirements for individuals has been reinstated. This system will be overseen by the Coordinator, families will be reminded 2 months in advance of all approaching appointments, stipends will be withheld for those not in compliance. 08/23/2017 Implemented
SIN-00232487 Renewal 10/11/2023 Compliant - Finalized
SIN-00158607 Renewal 07/09/2019 Compliant - Finalized
SIN-00135561 Renewal 07/10/2018 Compliant - Finalized
SIN-00099718 Renewal 07/06/2016 Compliant - Finalized
SIN-00065522 Renewal 07/09/2014 Compliant - Finalized