Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00123290 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The large bathroom has a worn-out toilet seat, the basement sump pump has a loose and warped cover, and the outside side ramp has a loose and warped board.Floors, walls, ceilings and other surfaces shall be in good repair. The toilet seat has been replaced 08/10/2017 (Attachment #15). The sump pump cover has been replaced with one made of diamond plate 08/16/2017 (Attachment #16). The outside ramp has been repaired 08/10/2017 (Attachment #17) Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. 08/16/2017 Implemented
6400.76(a)The living room sofa has on its right arm, cut fabric. Furniture and equipment shall be nonhazardous, clean and sturdy. A purchase requisition has been submitted to replace the torn furniture (Attachment #18). Fiscal office will process payment and delivery will be scheduled. Any furniture considered hazardous should be noted on monthly residential safety checklists (Attachment #4) and monthly compliance checklists (Attachment #5) so furniture can be repaired or replaced in a timely manner. 12/15/2017 Implemented
Article X.1007Delta is required to maintain criminal history checks. Staff#1 date of hire was 03/06/17 but there was no documentation of Pa. residency or completion of a FBI clearance.r When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.All new hires sign an affidavit to validate PA residency. Associate Director of Human Resources revised the new hire tracking form to document if affidavit was signed (Attachment #1). The recruiter and the human resources clerk are both responsible for double checking residency, ensuring the affidavit is signed, and that an FBI check is completed accordingly. 08/01/2017 Implemented
SIN-00063890 Unannounced Monitoring 05/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 did not have an up to date financial record. Funds totaling $9.17 were missing. Individual #2 did not have an up to date financial record. Funds totaling $ 205.63 were missing (2) Disbursements made to or for the individual. Individual #1 was reimbursed $205.63 on 4/30/14. Individual #2 was reimbursed $9.17 on 5/14/14. 1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached.3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. 06/06/2014 Implemented
6400.22(e)(3)Individual #2 was missing receipts for $205.63. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Increase training and management review of monthly ledgers. Reviewed financial procedures. Error made by staff with performance issues and job abandonment.1. May 2, 2014 Residential Managers, Project Directors and Associate Directors trained in Monthly Compliance Checklist. Finances are part of the monthly management documentation. (please see attached) Sign In Sheet for the Residential Managers meeting is attached. The Residential Managers meeting agenda is attached.2. We offer monthly training in "petty cash" which includes finances for the home and individuals. Schedules for April and May are attached. List of the staff trained in these 2 months is attached.3. Revised Monthly Consumer Fund Transaction reports to document the Project Director/Associate Director review. Please see attached forms. Implemented for 06-01-14. Management will review receipts and ledgers on a weekly basis. 06/06/2014 Implemented
SIN-00061198 Renewal 02/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual # 1 refused his physical on 1/27/14, last physical was completed on 2/1/13, and he also refused his prostate exam on 5/15/13. This individual has a refusal plan dated 11/11/13, but this plan was not implemented.(a) If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. As a result we are reviewing all of the individuals who have refused appointments. We are reviewing their refusal plans and the documentation of the follow-up. We developed a medical appointment refusal follow-up form to document reasons for refusal, implementation of Plan of Support and strategies for the future. A copy of the form will be forwarded to you. On 2/24/14 Associate Director and Project director completed medical appointment refusal documentation for the physical dated 1/27/14. Globally, we are looking at all individuals who refuse appointments and ensure proper documentation. Documentation and follow-up is the responsibility of Project director and Associate Director. Training will occur for the implementation of the document on 4/2/14. We will track our medical appointment refusal documentation in Evolv. 04/02/2014 Implemented