Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239146 Renewal 03/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At the time of the inspection, there was a hole in Individual #1's closet door. Screens, windows and doors shall be in good repair. Upon discovery of a hole in a closet door in bedroom #3 by the licensing inspector, program specialist immediately reached out to a contractor on 3/13/24 and asked for the door to be replaced. Contractor visited the house on 3/21/24 to measure the door in order to get a replacement. Program Specialist received an email from the contractor stating he will have the replacement door completed by 4/11/24. (See attachment #6a) 04/18/2024 Implemented
6400.80(a)At the time of the inspection, there was a large crack in the sidewalk outside of the hallway exterior door. Outside walkways shall be free from ice, snow, obstructions and other hazards. Licensing inspector discovered a large crack in the sidewalk outside the side doorway of the home. Program Specialist immediately reached out to a contractor on 3/13/24 and asked for the sidewalk to be repaired or replaced. Contractor visited the house on 3/21/24 to inspect the damage and give report to director if it can be repaired or if it needs replaced. Program Specialist received an email that contractor anticipates the replacement of the sidewalk or repair of the sidewalk will be completed by 4/11/24. (See attached #7a) 04/18/2024 Implemented
6400.141(c)(7)Individual #1's Pap exam was completed 12/2020. An additional attempt was made on 4/21/23, however, it is documented that the individual was "uncooperative." The next Pap was recommended for 12/2025. There is no medical reason stated for why the exam should be delayed. Additionally, the medical professional also stated that the exams should be completed yearly on a Provider created form, signed 4/21/23.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. Program Specialist contacted the individual's gynecologist and discussed the need for individual # 1 to have a Pap test, gynecological exam, and a breast exam on an annual basis on 3/19/24. The practitioner reviewed individual # 1's file and made the correct determination and indicated it on a letter stating the appropriate frequency for the examinations to be completed for this individual. 04/15/2024 Implemented
SIN-00188015 Unannounced Monitoring 05/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)One of the bathrooms in the home did not have hand soap. A second bathroom did not have hand soap, hand towels/or paper towels, nor a waste basket.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. Staff recently cleaned the bathroom and did not replace hand soap, paper towels, and wastebasket on the date of the inspection. Hand soap, paper towels, and wastebasket were replaced immediately after inspection on 5/26/21, by RPS. RPD checked the bathrooms for the necessary items on 5/27/21 and they were present in all bathrooms. Other homes bathrooms were monitored for the presence of the required items in 6400.82(f). They were found to be compliant. A monitoring tool was created by RPD on 6/4/21 to be completed by RPS at least monthly for 3 consecutive successful months, ensuring all the necessary items are present in each bathroom. If items are not present, they will be replaced immediately by RPS and staff will be trained on the necessary items need in facility restrooms. RPD will review the tool monthly, for each home, to ensure compliance. This tool was emailed to the agency management for agency-wide use on 6/8/21. See Attachments #3a, #3b, #3c, #3d and #3e. 09/01/2021 Implemented
6400.141(c)(6)Individual #1 last had TB testing completed on 3/5/19 and not again since, placing the test outside of the biannual time frame.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 #1 received her TB test on 5/26/21 and it was read on 5/28/21 (negative). RPS reviewed other individuals physicals for the absence of compliant TB testing on 6/7/21. One deficiency was found, however, the individuals physician noted that the TB was required to be late due to the proximity of individuals COVID-19 vaccine and the TB test. RPD created a monitoring tool on 6/7/21, to be used by RPS or RPD, at least monthly, to review charts for upcoming physicals and Mantoux testing, for at least 3 consecutive successful months. If a physical is due, RPS will review the monitoring tool to check if a TB test is due at that particular physical appointment. The current agency physical was amended by RPD on 6/8/21 to include a review of the TB due date, as the first item on the portion of the physical that is prepopulated by agency staff. If TB test is required at this annual physical, RPS will indicate the need on the physical form prior to the annual physical. RPD will review the monitoring tool monthly for completion. The monitoring tool and new, amended physical were emailed to the agency management for agency wide usage on 6/8/21. See Attachments #4a, #4b, #4c, #4d, #4e and #4f. 09/01/2021 Implemented
6400.141(c)(7)(Repeat from inspection dated 8/26/20) Individual #1 last had a Pap Test on 7/25/19 and not again since; placing the exam outside of the annual time frame.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. Individual #1 did not have a PAP test completed in 2020 due to the gynecological clinic being closed for routine screenings for a period time due to the COVID-19 pandemic. Individuals PAP test was attempted on 3/30/21, but was unsuccessful due to individual being uncooperative. On consult dated 3/30/21, gynecologist wrote a note this date that individual is due for a PAP test in 2022. Other individuals files were reviewed by RPS on 6/7/21, for compliance of PAP testing being completed within the annual timeframe. No late PAP tests were found. RPS reviewed scheduled appointments for all female individuals on 6/7/21, to ensure upcoming required PAP test was scheduled. A monitoring tool was created by RPD on 6/7/21 to track PAP testing due dates and when these appointments were scheduled. This tool will be completed by RPS or RPD, at least monthly for 3 consecutive successful months, and will be reviewed monthly by RPD for completion. This tool was emailed to agency management for agency wide use on 6/8/21 by RPD. See Attachments #5a, #5b and #5c. . 09/01/2021 Implemented
6400.141(c)(8)Individual #1 last had a Mammogram on 2/21/20 and not again until 3/30/21; placing the exam outside of the annual time frame.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Individuals mammogram wasn't completed within the annual time frame, due to the inability of the breast imaging clinic having an open appointment until 3/30/21. The COVID-19 pandemic has the breast imaging center behind on scheduling due to being closed for routine exams for several months. Documentation was received by RPD on 5/26/21 showing agency staff requested a mammogram for individual on 2/22/21 and breast imaging center scheduled it on 3/30/21. It is the breast imaging centers policy to schedule preventative exams only after 365 days have passed since the last exam. RPS called breast imaging center again on 6/7/21, to change the process of the way we schedule preventative exams (i.e. mammograms). RPS requested the ability to schedule a year ahead of time, one day after last exam. Ebensburg Care Center stated on 6/7/21, an exception would be made to the protocol they currently use for scheduling preventatives, for our agency. Ebensburg Care Center stated they would allow us to schedule gynecological appointments and mammograms a few months ahead of time, however, we must call for the physicians order a few days prior to the scheduled appointment or the appointment will be cancelled. All mammograms were scheduled by RPS then on 6/7/21. Other files were reviewed for annual compliance of mammograms by RPS on 6/7/21. Other deficiencies were found and corrected. A monitoring tool was completed by RPD on 6/7/21 for the use of the RPS to check that mammograms are scheduled within the required annual timeframe, at least monthly for 3 consecutive successful months. RPD will review the tool for completion, at least monthly. This tool was emailed to agency management for agency wide use on 6/8/21 by RPD. See Attachments #6a, #6b and #6c. 09/01/2021 Implemented
6400.32(d)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. On 5/26/21, Staff #2 was witnessed to be at the home without a mask on, when licensing staff arrived for the inspection. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual shall be treated with dignity and respect.Staff who was discovered not wearing a mask at the time of inspection, was retrained on 5/26/21 by RPD on the agency policy on mask usage. Other homes staff were monitored for mask usage on 5/28/21 and 6/1/21 by RPD and RPS and all staff were wearing their masks correctly. Each home will be monitored weekly by RPS for compliance from staff on mask usage for 3 consecutive successful months or until the policy on mask usage changes. This will be documented on a monitoring tool created by RPD on 6/7/21. RPD will ensure the monitoring tool is completed weekly by RPS and is signed off on. This tool was emailed to agency management for agency wide use on 6/8/21 by RPD. See Attachments #7a, #7b, #7c and #7d. 09/01/2021 Implemented
6400.166(a)(2)The Medication Administration Record (MAR) for Individual #1 did not include the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.RPS documented each prescribing physician on each medication listed on the MAR, for individual #1, on 5/27/21. All individuals MARs were updated with each prescribing physician for each medication on 5/28/21 by staff. RPS reviewed all MARs at the home on 6/4/21 for completion. All staff in our other homes were instructed to add the prescribing physician to each corresponding medication listed on the MAR on 6/4/21 by RPD. The pharmacy, who prints the monthly MARs, was contacted on 5/28/21 by RPS to have prescribing physician added to each medication listed on the MAR for months going forward. The pharmacy discussed different ways of adding the prescribing physician to each MAR block with the RPD on 6/9/21. A format was agreed upon and pharmacy stated that the MARS will be preprinted with prescribing physician starting for the month of July 2021 and going forward. RPD created a monitoring tool, to be completed by RPS at least monthly for 3 consecutive successful months, checking that each med on every individuals MAR has a prescribing physician listed on the MAR block containing the order. RPD will ensure the monitoring is complete, at least monthly and will sign off on the tool. This tool was emailed to agency management for agency wide use on 6/8/21 by RPD. See Attachments #8a, #8b, #8c and #8d 09/01/2021 Implemented
SIN-00141567 Renewal 10/31/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The carpet in the living room, the activity room and the hallway was very stained with brown spots all over the carpet, approximately 3 feet in diameter.Clean and sanitary conditions shall be maintained in the home. The Executive director at Cambria Residential Services, Inc. will solicit bids for the replacement of the carpeting in the living room, activity room and hallway of 167 Woodland Boulevard by November 30, 2018. Once bids have been solicited and a contractor has been selected by Cambria Residential Services, the carpeting will be replaced and in good repair by March 1, 2019. An inspection for clean and sanitary conditions (specifically carpeting) , in all of the agency homes, will be conducted by program specialists by 12/14/18. If unsanitary conditions such as stained carpeting is found, an agency request will be completed and contractors will be contacted to repair the unsanitary condition such as stained carpeting. An item was added to the agency home safety checklist, prompting all agency staff to check all homes for sanitary conditions (ex: stained carpet). These home safety checklists are completed monthly by agency staff and are reviewed monthly by agency Program Supervisors and/or Program Specialists. CEO will review monthly home safety checklists quarterly. See Agency Request dated 11/05/18 and Home Safety Checklist. 03/01/2019 Implemented
6400.65The vent in the right bathroom was not operable. The bathroom did not contain a window.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. A request for repair of the second bathroom on the right side of the hallway was completed by program supervisor on 11/5/18. Program supervisor then placed a service call to the company responsible for handling ceiling ventilation repair on 11/5/18 The vent on the ceiling of the second bathroom on the right side of the hallway will be repaired and in operable condition by November 30, 2018. An inspection of all ventilation, in all of the agency homes, will be conducted by programs specialists by 12/14/18. If ventilation is found inoperable or non-existent, an agency request will be completed and contractors will be contacted to repair the ventilation issue. An item was added to the agency home safety checklist, prompting all agency staff to check all homes for proper ventilation. These home safety checklists are completed monthly by agency staff and are reviewed monthly by agency Program Supervisors and/or Program Specialists. CEO will review monthly home safety checklists quarterly. See Agency Request dated 11/05/18 and Home Safety Checklist. 12/14/2018 Implemented
6400.66The front porch light was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A request for repair of the front porch light was completed by program supervisor on 11/5/18. Program supervisor then placed a service call to the company responsible for handling light fixture repair on 11/5/18. The front porch light will be repaired and in operable condition by November 30, 2018. An inspection of all exterior lights in all of the agency homes will be conducted by programs specialists by 12/14/18. If an exterior light is found inoperable, an agency requested will be completed and contractors will be contacted to repair the light. An item was added to the agency home safety checklist, prompting staff to check all exterior lights for operability. These home safety checklists are completed monthly by agency staff and are reviewed monthly by agency Program Supervisors and/or Program Specialists. CEO will review monthly home safety checklists quarterly. See Agency request dated 11/05/18 and Home Safety Checklist. 12/14/2018 Implemented
6400.67(a)The kitchen counters were racked and missing pieces. The kitchen cabinets and drawers were falling apart. The handicapped sink in the kitchen had exposed pipes. The wood surrounding the sides of sink was falling apart.Floors, walls, ceilings and other surfaces shall be in good repair. An agency request was completed by Program Specialist for the replacement of kitchen countertops, cabinets, drawers, handicapped sink and carpeting on 11/5/18. The Executive director at Cambria Residential Services, Inc. will solicit bids for the replacement of the kitchen countertops, kitchen cabinets, kitchen drawers, and replacement of handicapped sink of 167 Woodland Boulevard by November 30, 2018. Once bids have been solicited and a contractor has been selected by Cambria Residential Services, the carpeting will be replaced and in good repair by March 1, 2019. This will be monitored by the program supervisor and program specialist of 167 Woodland Boulevard to ensure It was completed. All agency homes will be inspected by their program specialists, by 12/14/18, for floors, walls, ceilings, and others surfaces being in good repair. Agency requests will be issued if there are any homes found with surfaces in unsatisfactory repair. An item was added to the home safety checklist to prompt staff, monthly, to check all floors, walls, ceilings, and other surfaces for disrepair. Home Safety checklists are reviewed by Program Supervisor and/or Program Specialists on a 03/01/2019 Implemented
6400.82(f)All 3 bathrooms did not contain hand soap.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. Hand soap was placed on the sinks, in all 3 bathrooms, on 11/1/18 by program specialist. A memo was issued to and signed by all full time staff at 167 Woodland Boulevard informing staff that all bathrooms should have hand soap, paper towels, toilet paper and trash receptacles readily available in all bathrooms. This memo was written on 11/5/18 and will be signed by all staff by November 30, 2018. See Memo issued to staff 11/5/18. Monitoring visits will be conducted weekly for 3 months to ensure the aforementioned items are readily available to those living in the home. These weekly monitoring visits will be documented by the program supervisor. Program specialist will sign off that that monitoring is completed. An item inquiring if hand soaps, paper towels, toilet paper and trash receptacles are readily available in the homes was added to the home safety checklists that are used agency wide. See Home Safety Checklist. Staff completed home safety checklists monthly and program supervisors/specialists review home safety checklists monthly. CEO will review monthly home safety checklists quarterly. 11/30/2018 Implemented
SIN-00204656 Renewal 05/10/2022 Compliant - Finalized
SIN-00189769 Renewal 06/29/2021 Compliant - Finalized