Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00187737 Renewal 05/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Documentation that the fire drill held during the month of 10/2020 was not provided. An unannounced fire drill shall be held at least once a month. We have changed our system for completion of the monthly fire drills. The drills are now being completed and submitted to the Director of IDD Services directly for monitoring completion in a timely and accurate manner during the month. We have eliminated the previous process of multiple levels of monitoring which led to the moth passing before the Director was aware that the fire drill had not been completed. 05/27/2021 Implemented
SIN-00123299 Renewal 08/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
Article X.1007Delta is required to maintain criminal history checks as per OPSA regulations. Staff #1's date of hire 6/5/17, the criminal background check was completed 6/7/17.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.Upon further checking, the recruiter noted that the system was done on 06/05/2017. Going forward, no new employee will be permitted to start orientation training until confirmation of all necessary criminal checks being completed prior to start date. Human Resources staff will check status of required criminal checks prior to employee starting orientation and again when employee arrives to start orientation. If any required criminal check is not completed for any reason, the employee will not be permitted to start until completed. 11/20/2017 Implemented
SIN-00091517 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff # 1's annual medication administration training dated 11/15/2015 was invalid as the fourth MAR review was completed on 12/14/2015. Staff # 20's annual medication administration training dated 11/03/2015 was invalid as the fourth MAR review was completed on 12/14/2015. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
SIN-00047525 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.14(a)The home does not have a valid fire safety occupancy permit. The home is licensed for 4 and one person required physicial assistance to evacuate the home on 10/3/12, 10/6/12, 11.11.12, 12/7/12, 1/16/13, 2/5/13 and 3/2/13.(a) If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh, the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: RecordsWe have identified a home with an existing C1 Certificate of Occupancy for the individual to move to. In the interim the individual will be using her walker with staff providing physical assistance as needed to ensure safe and timely evcauation. This procedure has been put in writing and staff were trained on 4/22/13. Documentation will be scanned and emailed. 04/30/2013 Implemented
6400.104On 4/1/12, 4/18/12, and 5/2/12 the patio sliding doors were used to exit during monthly fire drills and on 6/6/12, 6/9/12, 7/18/12, and 8/3/12 the front door was used to exit the home during monthly fire drills.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Revised letter sent 3/27/13. Director will more closely monitor fire safety and notifications to fire department. See supporting documentaion that has been scanned and emailed. 03/27/2013 Implemented
6400.141(c)(15)Special diet instructions to not lay down for 2-3 hours after eating was not included on physical examination completed 10/1/12.(15) Special instructions for the individual's diet. received diet instructions on 3/27/13. Staff were trained on 3/30/13. PD will ensure better clarification from physician and staff training. 03/30/2013 Implemented
6400.144Prescribed medical health care to complete yearly hemeoccult labwork was not completed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. physician discontinued the need for hemeoccult on 4/8/13. pd will closely monitor medical follow-ip 04/08/2013 Implemented
6400.181(f)There was no documentation that a assessment completed 10/5/12 was sent to the Support Corrdinator 30 days prior to the meeting date for ISP held on 11/12/12.(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). PD will ensure that cover letters are sent with each assessment prior 30 days to ISP meeting. Staff were trained 4/3/13. 04/03/2013 Implemented
6400.186(c)(2)ISP review completed 4/6/12 did not include a complete review of the ISP.(2) A review of each section of the ISP specific to the residential home licensed under this chapter. The ISP review which was sited was completed on 4/6/12 prior to the form being updated to include all areas of the ISP. PD will ensure the new format is used. Staff trained 4/3/13 04/03/2013 Implemented
SIN-00044711 Unannounced Monitoring 12/20/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(c)Individual # 1 supervision protocals in the ISP required 2 staff on duty. On the evening in question 12/09/12, only one staff was on duty at 382 Blue Ridge dr., Levittown, pa.(c) An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual's ISP, as an outcome which requires the achievement of a higher level of independence. We have reviewed the ISP ratio requirement with multiple levels of supervision. The residential manager was trained on 1/3/13 in staffing, the need for staffing ratios to be maintained on a consistent basis as per ISP. On 12/21/12 she received training on individual emergency procedures and protocals when individual is involved in an incident. This information was also review at Residential manager meeting by Project Director on 12/20/12. Staffing ratios as per ISPs was reviewed at the monthly agency Residential Mangers meeting on 1/11/13. 01/21/2013 Implemented