Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00180133 Renewal 11/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)It could not be determined at inspection if staff member #1's residency was established at employment, as a result, there was no FBI check found in the record.If 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. POC-11/25/2020 the agency that is used to obtain staff was trained on importance of the proper documentation that is needed to be employed within the company. Going forward the Scheduler will review all referral packets before staff are approved to work with the consumers. 11/25/2020 Implemented
SIN-00103802 Renewal 09/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessments were dated with three different dates making it undeterminable when the self assessment was completed.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Assistant Residential Directors will complete the self-assessment required under regulation 6400.15(a) for each COMHAR site 3 to 6 months prior to the expiration date of COMHAR¿s certificate of compliance on February 4. They will list only one date on that self-assessment, the date of completion of the self-assessment. The Lead Assistant Residential Director will monitor process and timeliness of completion. 12/21/2016 Implemented
6400.64(a)There were multiple brown, circular stains varying in size found on the shelves inside of the lazy Suzan.Clean and sanitary conditions shall be maintained in the home. The sauce that had spilled onto the bottom of the sauce bottle and stained the shelf of the lazy susan was wiped up and the bottom of the sauce bottle was cleaned. Site staff were reminded to wipe up residue on the bottle and the shelf and bottles before replacing into cabinets. 12/21/2016 Implemented
6400.68(b)The water temperature was measured at 138 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. COMHAR maintenance mechanic, Laurence Shivers, immediately went to site and adjusted water temperature down to lowest setting and tested to be sure it was below 120 degrees. This adjustment was followed up by ¿One Source Mechanical Services¿ who reset mixing valve to 112 degrees and tested water temperature at multiple outlets where temperature registered 112 degrees. Subsequent temp checks are registering at well below 120 degrees. Staff will hand test water for temperature prior to bathing or showering individuals residing at the site. Any temperature variance towards the maximum allowable will be identified and reported by DSP¿s to maintenance, assistant site manager and site manager for resolution. 12/21/2016 Implemented
SIN-00057024 Renewal 12/09/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(ii)There was no progress and growth listed on Individual #1's assessment dated 10/18/13 in the arears of communications or residential living.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (iii) Activities of residential living. Individual #1¿s assessment was amended to include progress and growth specific to motor and communication skills and activities of residential living. A revised, standardized Assessment form was developed and includes the missing skill/progress and growth areas that need to be responded to by the Program Specialist. Training for all Program Specialists on the proper items to be included in the Assessment and on the new form occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process. 01/31/2014 Implemented
6400.181(e)(13)(v)There was no progress and growth listed on Individual #1's assessment dated 10/18/13 in the arears of socialization or recreation. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (v) Socialization. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation. Individual #1¿s assessment was amended to include progress and growth specific to socialization and recreation skills and activities of residential living. A revised, standardized Assessment form was developed and includes the missing skill/progress and growth areas that need to be responded to by the Program Specialist. Training for all Program Specialists on the proper items to be included in the Assessment and on the new form occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process. 01/31/2014 Implemented
6400.181(f)Individual #1's ISP meeting was held on 10/13/13; the assessment is dated 10/8/13. (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). Going forward all Program Specialists will ensure that assessments are distributed to the SC and plan team members 30 days prior to an ISP meeting for the development, annual update and revision of ISP¿s. If the Program Specialist is unable to comply with this due to inadequate time notification of the plan meeting by the SC, the Program Specialist will document discrepancy in the individual¿s chart. Oversight of this requirement will be addressed by the Assistant Residential Directors for consistency purposes. Training for Program Specialists included proper protocols for timely dissemination of the Assessment and occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process 01/31/2014 Implemented
6400.186(a)Individual #1¿s ISP start dated was 1/12/13 The most recent 3-month ISP review was completed on 4/14/13. (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Individual #1's quarterly reviews had not been completed for review quarters 7/12/13 and 10/12/13. The missing reviews will be completed and brought up to date. The program specialist for individual #1 will undergo retraining regarding the necessity to complete quarterly reviews. Additional oversight for the program specialist will be provided by the Assistant Residential Director. 01/31/2014 Implemented
6400.186(c)(1)Individual #1¿s most recent monthly ISP review was completed 5/13. (c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Individual #1's monthly ISP reviews had not been completed from 6/13 through 11/13. The missing reviews will be completed and brought up to date. The program specialist for individual #1 will undergo retraining regarding the necessity to complete monthly reviews. Additional oversight for the program specialist will be provided by the Assistant Residential Director. 01/31/2014 Implemented