Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00121705 Renewal 09/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)The bottom of the light fixture near the staff room exit of the home was filled with approximately one and a half inches of insect carcasses causing a potential fire hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.On 10/5/17, the light fixture was taken apart and cleaned by maintenance department. A photo was emailed to [Human Services Licensing Supervisor]on 10/6/2017. The Residential Program Supervisor will conduct a full site inspection of each of their homes on a quarterly basis. CLA Home Visit Report Form that is used by the Residential Supervisors (RPSs) of each home includes "Checked house for damages/licensing non-compliance." The form will be updated to include utilizing the Pa site inspection tool (6400) on a quarterly basis. (This will be reviewed with the RPSs on 10/18/17 by the Assistant Program Directors (APDs). 10/05/2017 Implemented
6400.141(c)(7)The two most recent gynecological examinations for Individual #1 were 1/28/16 and 3/6/17The 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 Health Services Coordinator will ensure that all appointments are scheduled and send an appointment notification form to the group home indicating when the appointment is. The Health Services Coordinator or LPN will also input the appointment into THerap, our electronic software which includes an appointment tracker for all individual appts that was implemented in April 2017. This allows all staff and supervisors to view all scheduled appointments for all individuals. The Health Services Coordinator will also check weekly that all appointments have been attended and paperwork has been submitted to the Health Services Department. The Health Service Coordinator will also attend the Res team on 10/18/17 to remind all supervisors about the appointment tracking on therap and review at staff meeting for staff to check appointments at beginning of shift. 10/18/2017 Implemented
6400.141(c)(8)The two most recent mammograms for Individual #1 were 2/11/16 and 3/21/17.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The Health Services Coordinator will ensure that all appointments are scheduled and send an appointment notification form to the group home indicating when the appointment is. The Health Services Coordinator or LPN will also input the appointment into THerap, our electronic software which includes an appointment tracker for all individual appts that was implemented in April 2017. This allows all staff and supervisors to view all scheduled appointments for all individuals. The Health Services Coordinator will also check weekly that all appointments have been attended and paperwork has been submitted to the Health Services Department. The Health Service Coordinator will also attend the Res team on 10/18/17 to remind all supervisors about the appointment tracking on therap and review at staff meeting for staff to check appointments at beginning of shift. 10/18/2017 Implemented
SIN-00065037 Renewal 09/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1, admitted on 5/8/14, was not informed of her rights upon admission. Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. The Statement of Rights is reviewed with the individual/individual's parent/guardian upon admission to Residential Services. In the case of Respite Care services, the Statement of Rights will be reviewed with the individual on the first day of Respite Care services and then again on the 32nd day of Respite Care services. If Respite Care services continue past that time period until waiver monies are available to the individual for Residential admission, the Statement of Rights will be reviewed again with the individual/individual's parent/guardian upon admission date. The Statement of Rights is then reviewed annually as part of the annual resign packet. A dFs supervisor is responsible for reviewing the Statement of Rights with the individual. 10/17/2014 Implemented
6400.141(c)(7)Individual #1, admitted on 5/8/14, did not have a gynecological examination until 9/2/14.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. dFs will continue to follow the Policy and Procedure for Admission and On-Going Health Physicals. Supporting documentation is attached. Also, on 10-9-14, it has been added in the Policy and Procedure what will occur for Emergency Respite. Highlighted on the supporting documentation. The health Service Coordinator is responsible for assuring that this Policy is followed through for all individuals receiving residential services. 10/16/2014 Implemented
6400.141(c)(8)Individual #1, date of birth 8/31/49, was admitted on 5/8/14 and did not have a mammogram within the past year.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. dFs will continue to follow the Policy and Procedure for Admission and On-Going Health Physicals. Supporting documentation is attached. Also, on 10-9-14, it has been added in the Policy and Procedure what will occur for Emergency Respite. Highlighted on the supporting documentation. The health Service Coordinator is responsible for assuring that this Policy is followed through for all individuals receiving residential services. 10/16/2014 Implemented
SIN-00213601 Renewal 10/18/2022 Compliant - Finalized
SIN-00181164 Renewal 01/06/2021 Compliant - Finalized
SIN-00052694 Renewal 08/12/2013 Compliant - Finalized