Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00201391 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)The Annual fire safety training was not completed by a fire safety expert for staff member #2.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). The annual fire safety for staff #1 was not completed by a fire safety expert. On 3/21/22, the Director, Program Specialist, Trainer, and several Supervisors participated in the Fire Safety, train the trainer training, conducted by Gordon Smoko, CSP, CFPS, ARM with Brown and Brown. Certificates of completion can be found as attachment #1. 03/21/2022 Implemented
6400.46(g)Annual fire safety training for staff member#1 was not completed by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). The annual fire safety for staff #1 was not completed by a fire safety expert. On 3/21/22, the Director, Program Specialist, Trainer, and several Supervisors participated in the Fire Safety, train the trainer training, conducted by Gordon Smoko, CSP, CFPS, ARM with Brown and Brown. Certificates of completion can be found as attachment #1. 03/21/2022 Implemented
6400.46(i)Annual first aid training was not completed for staff member#1within the required timeframe. it was completed 7/19/19 and then again on 9/9/21.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. DEC purchased the Employee Care Module from Sandata Technologies on 3/18/22. 03/18/2022 Implemented
6400.151(a)Physical exam not completed within 2-year time frame for staff member#2. It was completed 10/7/19, and then again on 2/9/22. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The physical exam for staff #2 was not completed within the 2-year time frame. It was completed on 10/7/19 and then again on 2/9/22. DEC purchased the Employee Care Module from Sandata Technologies on 3/18/22. 03/18/2022 Implemented
6400.151(c)(2)The Tuberculin test was not completed for staff member#2 within the 2 year time-frame. I t was completed on 10/7/19, and then again on 2/9/22. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician¿s assistant or certified nurse practitioner. DEC purchased the Employee Care Module from Sandata Technologies on 3/18/22. 03/18/2022 Implemented
SIN-00182443 Renewal 02/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Individual #1 bathroom did not contain a trash receptacle.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.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. The bathroom in individual #1's room did not have a trash receptacle present during the time of inspection. A trashcan was purchased and placed into individual #1's bathroom (Attachment #1) on 2.13.2021 and the receipt was filed. 04/15/2021 Implemented
6400.32(e)Thermostat in home was locked and the house staff nor the individuals had a key. When the individuals do not have immediate ability to have the temperature in their home increased or decreased, they are denied their right to make choices.An individual has the right to make choices and accept risks.An individual has the right to make choices and accept risks. The thermostat was observed to be covered by a locked case, without an available key to access it. The Maintenance Director placed a key inside the home on 3.1.2021; all individuals and staff have access to the thermostat at all times. 03/01/2021 Implemented
SIN-00130361 Renewal 01/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)The kitchen gas stove had what appears as mice feces on top of the stove.There may not be evidence of infestation of insects or rodents in the home. There may not be evidence of infestation of insects or rodents in the home. Marshall street has monthly visits from Moyer pest control. The kitchen was thoroughly cleaned on 01/30/2018. Staff have been retrained in the procedures in place to notify on-call of all sightings or evidence of insects or rodents. The on-call staff shall notify the Maintenance Director who will contact Moyer pest control to complete a full inspection and treatment, as needed, for all reports. This procedure was written and all house supervisors were trained on 02-15-18. 02/15/2018 Implemented
6400.67(a)There were two knobs missing on the bedroom fold out closet door. The wall opposite the bathroom had scrapped off wall paper due to wheel chair damage. There were two double dressers in the bedroom missing knobs.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings, and other surfaces shall be in good repair. The knobs on the bedroom fold out closet door were replaced on 1/30/18, during inspection. The site observation form was updated to include dresser and closet knobs. The house supervisor was retrained on 03-23-18 in the completion of site observations to ensure all floors, walls, ceilings, and other surfaces are in good repair. 03/23/2018 Implemented
6400.186(a)Individual #1's ISP reviews dated 6/2/17 and 3/2/17 were signed prior to the end of the review period.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. 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. 02/01/2018 Implemented
SIN-00086983 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On 10/1/15 Individual #1 had a haircut in the amount of $17, and left a tip for $10, which was not used for the individuals benefit. Individual funds and property shall be used for the individual's benefit. Individual funds and property shall be used for the individual's benefit. Individual reimbursed for inappropriate tip amount. Tip sheets to be used by staff when taking an individual into the community for services. Residential Coordinator will review each individual peronal funds expentures to assure monies are used to their benefit. Addendum # 5. 01/29/2016 Implemented
6400.68(b)The water temperature in the hallway shower was 139° Fahrenheit . Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water was turned down on 11/19/15. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature is being checked and recorded on a daily basis by staff in all homes. Addendum # 4. 12/31/2015 Implemented
6400.141(c)(7)Individual #1's preadmission physical dated 7/22/15 did not include a gynecological exam, 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. The physical examination will 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. Checklist developed to assure all required medical testing is completed prior to admission into the home. Addendum # 3. 01/29/2016 Implemented
6400.213(1)(i)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 will 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. Basic information sheet revised and information added to each individual file. Addendum #1. 01/29/2016 Implemented
SIN-00092759 Unannounced Monitoring 10/20/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Crest Pro-Health Oral Rinse and Lady Speed Stick Deodorant, which indicated to contact poison control if ingested, was found unlocked in the bathroom cabinet above the sink. All the individuals in the home are unable to safely use poisonous substances. Germ X, Sea Cleanse Wound Treatment and petroleum jelly, which indicated to contact poison control if ingested, was found unlocked in Individual # 2's bedroom. All the individuals in the home are unable to safely use poisonous substances. Nail Polish Remover which indicated to contact poison control if ingested was found unlocked in the shared bedroom of Individual # 1 and # 3. All the individuals in the home are unable to safely use poisonous substances. Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials will be kept locked or made inaccessible to individuals. All poisonous are locked in hall closet, corrected during inspection. Monthly Site Checks are conducted by house supervisor and revised to include poisonous materials being locked. Addendum # 2. Training on BHSL licensing review, plan of correction, site safety and reporting repairs took placed on 12/29/2015. Addendum #3 CRD Director or designee reviews monthly forms to assure compliance. 12/29/2015 Implemented
6400.64(a)A dark stain approximately six inches by six inches was found on the carpet in the staff area. Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home. Monthly Site Checks are conducted by house supervisor and revised to clean and sanitary conditions. Site Visit/Observation Forms are completed at least weekly by management staff which also reviews the home cleanliness and needed repairs. Addendum # 2. Training on BHSL licensing review, plan of correction, site safety and reporting repairs took placed on 12/29/2015. Addendum #3 Monthly review of all forms by CRD Director for areas of concern. 12/29/2015 Implemented
6400.64(e)The trash receptacle located in the kitchen did not have a lid.Trash receptacles over 18 inches high shall have lids. Trash receptacles over 18 inches high will have lids. Lid located and placed on kitchen receptacles. Monthly Site Checks are conducted by house supervisor and revised to clean and sanitary conditions. Site Visit/Observation Forms are completed at least weekly by management staff which also reviews the home cleanliness and needed repairs. Addendum # 2. Training on BHSL licensing review, plan of correction, site safety and reporting repairs took placed on 12/29/2015. Addendum #3 Monthly review of all forms by CRD Director or designee to assure compliance. 12/29/2015 Implemented
6400.112(a)The fire drills are unannounced as there is a schedule provided to staff as to when a fire drill shall be held. Staff scheduled during the fire drill time frame is responsible for conducting the fire drills. An unannounced fire drill shall be held at least once a month. An unannounced fire drill will be held monthly. Fire drill procedures were revised and reviewed at management meeting on 10/21/2015. Only the staff responsible for conducting the drill knows the time of the drill, the schedules are no longer posted or accessible for all staff. Annual fire safety training and site specific training took place on 3/29/2016, procedure reviewed with all staff. Addendum # 1. Monthly oversight of all drills by Residential Coordinator. 03/29/2016 Implemented
SIN-00063494 Renewal 07/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 5/6/14 Individual #4's 1:1 staffing ratio was not provided between 1 am and 3 am . An individual may not be neglected, abused, mistreated or subjected to corporal punishment. A revised overnight e-mail procedure was implemented to ensure awake coverage is maintained. The CRD administrative assistant notifies the Residential Coordinator on a daily basis of any issues with the emails. There is a backup system in case of computer issues. Also overnight random check ins are in place on a quarterly basis; last one completed at Marshall Street was September 12, 2014. Additionally on call managers have all been re-trained in reporting procedures. Staff terminated due to lack of providing required care. 07/06/2014 Implemented
SIN-00049756 Renewal 07/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The home did not conduct fire drills during the months of October, 2012 November, 2012, and December, 2012. (a) An unannounced fire drill shall be held at least once a month. A random check on fire drills in January 2013. It was at this time we discovered some discrepancies which led to a full investigation. After the investigation, it was determined that fire drills were falsified and missing and the staff involved was terminated. Due to the time frame there was no way to go back and re-run fire drills to meet the regulation of having a fire drill on a monthly basis. While we cannot prevent falsification, we can closely monitor each drill in a timely manner so that any discrepancy is found within the same calendar month allowing for a valid drill to be run each month. Our plan of correction is as follows: 1. All staff was re-trained in fire drill specifics including filling out forms, necessity of accurate information and their signature indicates accuracy of the report. In addition to annual fire safety training in these specifics was done in April 2013 and will be done each year. 2. All fire drills submitted have and will continue to be verified by the administrative assistant by checking the alarm company report (protection one) online by the 28th of each month. If the information is inaccurate, the CRD Director will be notified and staff involved will be suspended pending the outcome of investigation. The Residential Coordinator will conduct another fire drill within 24 hours to ensure compliance. This has been in place since 1/28/2013 and all drills have been verified and documentation of verification was attached to each fire drill for review during annual inspection. 3. In the absence of the administrative assistance, the backup will be Residential Coordinator and in the absence of the CRD Director the Program Director will be notified of the discrepancy. 08/01/2013 Implemented
SIN-00220514 Renewal 03/02/2023 Compliant - Finalized