Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240600 Renewal 03/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was unlocked bleach in one of the upstairs closets. This was removed at the time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials, including cleaning supplies, will be locked up when not in use. the bleach in the bathroom was removed and disposed of on 3/6/24 at the time of inspection by the house supervisor. The department has protocols for storing all poisonous materials. 03/21/2024 Implemented
6400.207(4)(I)Individual #4 is prescribed Ativan as needed for extreme agitation and anxiety -- this is considered a chemical restraint.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The prescription for individual #4 for Ativan was for a limited time use. The department Medical Coordinator reached out to the prescribing psychiatrist to have the medication discontinued on 3/6/24 and 3/19/24. The medical coordiantor spoke to the psychiatrist on 3/6/24 and a discontinuation order was sent on 3/21/24. 04/06/2024 Implemented
SIN-00220513 Renewal 03/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)There is no exit route listed on the 4/3/22 drill. There is no indication if the smoke detectors were operable during the 4/3/22 drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. There is no indication that smoke detectors were operable during 1/28/23 drill. All components of the fire drill record (form) must be completed during a fire drill. The house supervisor will run a fire drill, complete the form accurately and to completion including checking that all smoke detectors are operable. The drill will be completed no later than 3/27/23. The House Supervisor will perform the correction required. The Residential Director will obtain the copy of the completed fire drill form with a due date of 3/27/23. 03/27/2023 Implemented
SIN-00182442 Renewal 02/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Dawn dishwashing liquid was observed in the same pantry as food.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. Dawn dish soap was in the same pantry with food. The soap was removed from the pantry, at the time of inspection and placed in a separate cabinet with other cleaning supplies. The director retrained all house supervisors in the regulations, reminding them that all poisonous materials must be stored away from food, food preparation areas, and dining surfaces. 04/15/2021 Implemented
6400.64(f)An outside trash can did not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. The trashcan outside is missing a lid. The old trashcan without a lid was picked up by the trash company on 3.25.2021. 04/15/2021 Implemented
6400.72(b)Laundry room window was not in good repair and could not be opened at the time of inspection. Screens, windows and doors shall be in good repair. Screens, windows and doors shall be in good repair. The window in the laundry room was not able to be opened at the time of inspection. The Maintenance team arrived shortly after the physical site inspection on 2.4.2021, to assess the window and reported that it was window was frozen shut due to the snow storm on 2/3/21 and low temperatures on 2/4/21 in the morning. Pictures were taken of the window which is now unfrozen and working. 02/04/2021 Implemented
6400.144PRN medications benzonatate cap 100 mg and ibuprofen 600 mg for individual #1 were not present in the home.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. 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. Individual #1 has two medications that are prescribed as PRN; neither medication was accessible in the home during the time of inspection. It was noted by the inspector that PRN medications must be in the home at all times. All PRN medication for all individuals, in all homes were reordered and are currently stored in the homes. 04/15/2021 Implemented
SIN-00130360 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a broken light in the dining room hanging from the ceiling. The lightbulbs were completely exposed. Furniture and equipment shall be nonhazardous, clean and sturdy. Furniture and equipment shall be nonhazardous, clean, and sturdy. The light was repaired on 02/12/2018. An individual broke the light on 1-14-18. The chandelier was replaced with track lighting on 03/20/18. The room will be assessed (heating vents, size, outlets, etc.) to develop a backup plan in the event that the track lighting is damaged. Correction Date:(required) 2/12/2018; 3/20/2018 and ongoing. 03/20/2018 Implemented
6400.144During the inspection the staff were unable to produce a order for diabetic testing involving individual #1. When asked a staff stated he should be tested once a day. According to his glucometer memory and an in house check this has not been completed daily. There is also no diabetic protocol for low or high sugars.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. 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. The house received parameters and protocols from individual #1¿s doctor on 3-1-18. Individual #1¿s MARS was updated to include a space for his Blood Sugar Reading. The house supervisor will review all blood sugar readings on a weekly basis to ensure documentation is completed. All staff were trained in the updated protocol and parameters. 03/30/2018 Implemented
6400.186(b)Individual #1's ISP review was signed on 7/12/17 which was prior to the end of the review period of 4/15/17 to 7/15/17. Also, the ISP review for 7/15/17 to 10/15/17 was signed on 10/12/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The ISP review signature sheet must be signed and dated by the program specialist and the individual upon review of the ISP. All Program Specialists were retrained on 3-1-18 on ISP reviews and reminded that there is a 15 day grace period; staff was directed not to complete work prior to the review date. The CRD director will monitor the completion date of reviews. The reviews that were completed after licensing date were completed and signed to include the full review period. 03/01/2018 Implemented
6400.186(c)(1)Individual #1 there was no monthly for July of 2017. The dates of goal were not updated from prior years.The ISP review must include the following: 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. The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months towards ISP outcomes supported by services provided by the residential home. A complete filed review was completed on 2-15-18 and all monthly summaries are in place and completed. The July 2017 monthly was completed and filed. The Program Specialist was retrained on 2-15-18 in the requirements for monthly documentation. The administrative assistant was trained in requirements for monthly documentation on 2-15-18 and will complete monthly file reviews to ensure all monthly documentation has been completed and placed into the files; all missing reports will be reported to the CRD Director. 02/15/2018 Implemented
SIN-00107136 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a strong smell of urine in Individual # 1's bedroomClean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home. Bedroom thoroughly cleaned on 2/8/2017. Home has a cleaning schedule; Supervisor is responsible to ensure cleanliness. CRD Director will track compliance with schedule. Completed site safety for 2/17 shows compliance. Attachment #1 All staff will be retrained on the site safety checklist and their responsibility in its completion. 04/28/2017 Implemented
SIN-00086982 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #2's bedroom carpet was stained and dirty.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions shall be maintained in the home. Carpet is being replaced with alternative flooring. Site safety checklist, which includes clean and sanitary conditions, will be completed by program designee on a monthly basis. Program Specialist will ensure that areas of concern are addressed in a timely basis (dd 2.9.16). Addendum # 3. 01/29/2016 Implemented
6400.141(c)(14)Individual #1's physical dated 2/4/15 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination will include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical coordinator will complete information prior to the examination for the doctor to sign off on the physical. Additional review of the physical form will be done by the medical coordinator. Addendum # 2. 01/28/2016 Implemented
6400.213(1)(i)Individual #1's record did not document information regarding eye color and hair color. Individual #1's record did not document information regarding religious affiliation. 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.Each individual's record willbinclude 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. Basic information sheet revised and missing data added to each individual's file. Moving forward the Program Designee will ensure each new admittance has all areas of the basic information sheet documented and or updated when completing quarterlies(dd 2.10.16) Addendum # 1. 01/28/2016 Implemented
SIN-00063493 Renewal 07/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathtub in the second floor bathroom had rust stains going down the side of the tub. Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions shall be maintained in the home. Rust has been added to the site safety checklist that is completed monthly. Therefore if any rust is present it will be reported via the site safety inspection and maintenance will corrected as needed. All work was started to clean the rust in the bathtub on 7/2/2014 and completed by 9/16/14. 09/16/2014 Implemented
6400.67(b)The handrail leading from the second floors fire escape was rusted. Floors, walls, ceilings and other surfaces shall be free of hazards.Floors, walls, ceilings and other surfaces shall be free of hazards. Rust has been added to the site safety checklist that is completed monthly. Therefore if any rust is present it will be reported via the site safety inspection and maintenance will corrected as needed. All work was started on 7/2/2014 and completed by 9/16/14. 09/16/2014 Implemented
6400.143(b)Individual #1 refused a mammogram on 3/10/14. The refusal plan dated 8/3/13, was not implemented. If an individual has a serious medical or dental condition, reasonable efforts shall be made to obtain consent from the individual or substitute consent in accordance with applicable law. See section 417 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. § 4417(c)).All Supervisors re-trained in the need to document the treatment refusal plans as written. The Program Specialist monitors monthly and communicate any issues to the CRD Director. Individual #1 TRP was implemented as documented on 8/4/2014 and 8/14/2014 and on the 4th 13th 22nd and 30th of September. 08/20/2014 Implemented
6400.186(c)(4)(ii)Individual #1's assessment dated 8/3/13; identifies education regarding mammograms and increasing cooking skills as recommended areas of training. These needs did not appear as outcomes in the ISP dated 12/23/13; nor was there documentation sent to the supports coordinator which identified that these outcomes needed to be added. The program specialist shall make a recommendation regarding the following, if applicable: The addition of an outcome or service to support the achievement of an outcome. Documentation will be kept via email of change in individual's need. Program Specialist retrained in both outcomes and recommendations. Ongoing training will be given around the assessment/ISP process and regulations incuding the need to notify Support Coordinators. The CRD Director will monitor the program specialist and complete random (sample) monthly reviews of assessments and supporting documentation. Individual #1's ISP was updated, which occurred on August 26, 2014, September 26, 2014 and will continue on a monthly basis. 08/05/2014 Implemented
SIN-00049755 Renewal 07/01/2013 Compliant - Finalized