Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239394 Renewal 02/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1 did not have an annual hearing screening as part of the annual physical examination that occurred on 3/08/2023, or completed by another medical specialist.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Doctor was phoned to schedule hearing exam, but was not scheduled due to individual being uncooperative for hearing exams. Hearing will be checked for functioning at next physical exam. 03/11/2024 Implemented
6400.166(b)Staff #1 did not record their initials on the Medication Administration Record (MAR) at the time they administered the 2 PM dose of Topiramate 50mg. on 2/27/2024 to Individual #1.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff #1 was given a med refresher following the missed initials. Supporting document submitted. 02/28/2024 Implemented
6400.213(1)(i)Individual #1's record did not document the individual's religious affiliation or preference.Each individual's record must include the following information: The religious affiliation.Individual #1 intake form updated to provide religious preference. 02/29/2024 Implemented
SIN-00212100 Unannounced Monitoring 08/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16According to Individual Support Plan (ISP) with a plan last updated date of 8/9/22, Individual #1 was to be supervised when eating. ISP states that "staff are present in the same room while he is eating. He is not a choking risk." "(Individual #1) is able to feed themselves independently; however, they require assistance pouring a drink for themselves, depending on the type of container being used. They is on a 1,750 ml fluid restriction. (Individual #1) needs to be watched around drinks because they will steal anyone's drink. They will occasionally grab drinks at home and at cps program." According to written statement taken on 8/5/22, Staff #1 was working alone at the time of the incident. Staff #1 reports coming from the downstairs area after changing the laundry and witnessing a container of parmesan cheese open and spilled on the counter and Individual #1 leaving the kitchen and heading back to the bathroom. Staff #1 states they then put laundry in the dryer, cleaned the parmesan cheese, changed the garbage bag and put the old garbage bag by the door before checking on Individual #1 in the bathroom. As Staff #1 made their way to the bathroom, they heard Individual #1 choking. Staff #1 immediately called 911 and performed mouth sweeps and the Heimlich maneuver until Emergency Medical Staff arrived. Individual #1 was transported by ambulance to Geisinger CMC's ICU. Individual #1 passed away on 8/11/22 after the decision was made to remove ventilation. Staff #1 stated in an interview on 8/29/22 that " I did not check (Individual #1) right away because (Individual #1) had no issues." Staff #1 reports having direct knowledge that Individual #1 had consumed the parmesan cheese and was neglectful in not providing the proper supervision per the ISP when they noted that Individual #1 had ingested food in the form of the parmesan cheese.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.The Individual Service Plan, (ISP), for Individual #1, Section Meals/Eating, (Page 15) is not comprehensive. The statement, ¿Staff are present in the same room while (They) are eating¿, is incomplete. Statement in ISP should read: Individual #1 is able to eat independently and follows a regular diet. Fluids are restricted to 1750 ML per day. Staff provide assistance to pour a drink and to cut tougher foods. When dining with others, staff will implement the Behavior Support Plan- Outcome Number 3- to address target behavior of taking food and beverages of others. Individual #1 has no incidents of choking. Supportive Documents: 1. Positive Behavior Support Plan - June 17, 2022 2. Statement Behavior Specialist - October 4, 2022 3. Staff training sign off documents for ISP and BSP. 12/16/2022 Implemented
6400.186On 8/3/22 Individual #1 was reported to have ingested and choked on parmesan cheese. According to the Individual Support Plan (ISP) with a plan last updated date of 8/9/22, Individual #1 was to be supervised when eating. ISP states that "staff are present in the same room while (Individual #1) is eating. (Individual #1) is not a choking risk. (Individual #1 is able to feed themselves independently; however, they requires assistance pouring a drink for themselves, depending on the type of container being used. They are on a 1,750 ml fluid restriction. (Individual #1) needs to be watched around drinks because they will steal anyone's drink. They will occasionally grab drinks at home and at cps program." Additional information in the Behavioral Support Plan (BSP) included in the ISP reads "Staff will monitor (Individual #1) closely around the food and beverages of others. Staff will provide redirection and verbal counseling should (Individual #1) attempt to take food. "(Individual #1) will take the food and beverages of others. (Individual #1) should be monitored closely around food and beverages." According to a written statement taken on 8/5/22, Staff #1 states that Individual #1 was in the bathroom while Staff #1 went downstairs to do laundry. Upon returning to the upstairs area, Staff #1 saw an open container of parmesan cheese on the kitchen table and Individual #1 leaving the kitchen area and returning to the bathroom. Staff #1 then changed the laundry, cleaned up the spilled parmesan cheese, changed the garbage bag in the kitchen and placed it by the door to be taken out. Staff #1 then went to check on Individual #1. Staff #1 stated in an interview on 8/29/22 that they "did not check (Individual #1) right away because (Individual #1) had no issues". Upon reaching the bathroom, Staff #1 heard the sounds of Individual #1 choking. Staff #1 immediately called 911 and performed mouth sweeps and the Heimlich maneuver until Emergency Medical Services arrived. Individual #1 was transported by ambulance to Geisinger CMC's ICU. Individual #1 passed away on 8/11/22 after the decision was made to remove ventilation. "Staff #1 reports having direct knowledge that Individual #1 had consumed the parmesan cheese and was neglectful in not providing the proper supervision per the ISP when they noted that Individual #1 had ingested food in the form of the parmesan cheese. In not checking on Individual #1 immediately upon the discovery that it was likely they had ingested food Staff #1 did not implement the ISP as written.The home shall implement the individual plan, including revisions.The Individual Service Plan, (ISP), for Individual #1, Section Meals/Eating, (Page 15) is not comprehensive. The statement, ¿Staff are present in the same room while (They) are eating¿, is incomplete. Statement in ISP should read: Individual #1 is able to eat independently and follows a regular diet. Fluids are restricted to 1750 ML per day. Staff provide assistance to pour a drink and to cut tougher foods. When dining with others, staff will implement the Behavior Support Plan- Outcome Number 3- to address target behavior of taking food and beverages of others. Individual #1 has no incidents of choking. Supportive Documents: 1. Positive Behavior Support Plan - June 17, 2022 2. Statement Behavior Specialist - October 4, 2022 3. Staff training sign off documents for ISP and BSP 12/16/2022 Implemented
SIN-00184401 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual #3 did not have a mirror in his bedroom at the time of inspection. Review of individual's ISP does not indicate safety concerns related to the individual having a mirror.In bedrooms, each individual shall have the following: A mirror. As per regulation 6400.81(k) 6, a non-breakable mirror was purchased on 3/31/21. Once received, Arc maintenance will install in individual#3 bedroom. See attached receipt 03/31/2021 Implemented
6400.141(a)Individual #2 did not have an annual physical for the year 2020. The last physical on file was dated 6/11/19. Documentation dated 3/12/21 indicated that the individual was unable to have a physical due to COVID 19, however, no documentation was provided that the appointment was cancelled/rescheduled during the 2020 year.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #2 was able to have his physical completed on 3/10/21. ( See attached) In the event a physical can't be done, proper documentation as to the reason shall be kept on file. 03/10/2021 Implemented
6400.141(c)(6)Individual #2 has a history of adverse reaction/false positive to the traditional turberculin skin testing. Individual #2's primary care physician has it documented to that the individual should receive chest x-rays every 5 years in place of the traditional skin test. Individual last had a chest x-ray on 3/26/15 and was due for updated chest x-ray 3/26/2020. This was not documented as completed in the individual's file nor were any physician orders obtained to defer the chest xray during the COVID-19 pandemic.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #2 had a chest x-ray done on 3/10/21 at the time of his physical (see attached). In the event of a procedure can't be completed, documentation shall be completed to support the reasoning for the non-compliance or cancelation. 03/10/2021 Implemented
6400.52(c)(6)Staff #1 did not receive training on the implementation of the individual plans for two of the four individuals he works with.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.As per regulation 6400.52c 6, staff will review individuals ISP prior to working with the person and annually thereafter. On 3/30/21 staff was trained on the ISP's of the two individuals and documentation of such training was completed. See attached 03/30/2021 Implemented
SIN-00169136 Renewal 01/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The storm door on the side of the house could not be open at the time of this inspection. This exit would not be able to be utilized in the event of a fire.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The storm door was repaired by maintenance. Prevention: During daily poison checks in the home, exits will be also be checked to ensure that they are unobstructed and noted on the revised daily checklist form. Staff within the home will be trained on the purpose and regulation re: this safety issue. All other homes were checked to ensure compliance. No other doors/exits were obstructed. 01/22/2020 Implemented
SIN-00108227 Renewal 03/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The individuals in this home are not poison safe and the soaps placed throughout the home stated to call a physician or poison control if ingested. Poisonous materials shall be kept locked or made inaccessible to individuals.Toxic soap was removed immediately and hand soap has been changed to a non- toxic type. 03/22/2017 Implemented
6400.68(c)The coliform water testing was performed late two times, 03/21/16, then not again until 07/05/16 then 09/12/16 and not again until 12/27/16.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Water coliform testing with be completed every 2 months. Most recent testing is 3/3/17 and 5/3/17/ 03/30/2017 Implemented
6400.163(c)Individual #1's three month med review was late. 03/29/16, 06/21/16, 09/13/16, and then not until 01/03/17. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Program Specialist now monitoring necessary appointments on a monthly basis during home visits. In addition, supervisor and Program Specialist now share a calendar of appointments. Training on 6400.163 was held for Program Specialist and supervisors on March 30, 2017. Most recent med review for individual number #1 - March 21, 2017. 03/30/2017 Implemented
6400.171There was a slab of meat in the freezer sitting on a piece of styrofoam with no covering. It was stored without protection, not ensuring that it was protected from contamination.Food shall be protected from contamination while being stored, prepared, transported and served. Meat was promptly removed and discarded. Training implemented with supervisory and Program Specialist staff regarding food storage, (6400.171). Staff at home also retrained. 03/22/2017 Implemented
6400.213(1)(i)Individual #1's file does not conatin any information regarding religious affiliation or a current dated photo. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Religious affiliation and current dated photo have been added to the file. Supervisory staff and Program Specialist reviewed Chapter 6400.213(1) (I). Program Specialist will review personal information form monthly. 03/22/2017 Implemented
SIN-00069104 Renewal 01/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The left side of the main hallway has two large areas that were damaged and patched but need to be painted. Floors, walls, ceilings and other surfaces shall be in good repair. Corrected on 2/11/2015 the entire hallway wall was painted by maintenance Joseph Sepe. Pat Quinn, Director, and Lisa Jezorwski, Supervisor, will be responsible to ensure compliance and safety. 02/11/2015 Implemented
6400.68(c)Coliform water testing was done on 12/23/2013 , 04/04/2014, 07/30/2014 and 10/10/2014. The three month ( minimum ) limit was exceeded between December and April as well as between April 4th and July 30th.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Corrected 1/9/2015 Correction: Reviewed regulation 6400.68(C) with supervisors and program specialists at all homes (Silver Meadow & Orchard Dr.) and discussed the need to have tests completed within 90 days and not every 3 months. Water testing dates marked in all program specialists¿ and supervisors¿ calendars. A water test was completed on 1/8/2015 at Silver Meadow and will be repeated prior to 4/6/15. Person responsible for ensuring compliance is Sheila Nealon, Program Specialist. 01/09/2015 Implemented
6400.72(b)The basement screen in the sliding screen door is torn and needs to be replaced. Screens, windows and doors shall be in good repair. Corrected on 2/11/2015 Property Manager, Joseph Sepe, took the basement screen door to Scranton Grinder and had the screen replaced. He installed it on 2/11/2015. Patrick Quinn, Director 02/11/2015 Implemented
SIN-00147555 Renewal 01/23/2019 Compliant - Finalized
SIN-00089408 Renewal 02/02/2016 Compliant - Finalized