Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00207668 Renewal 06/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The door to the attic had a latch lock with a combo preventing immediate exit from room if lock was engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The combination lock was removed during inspection by the Executive Director which provides for immediate exit from attic. 07/19/2022 Implemented
6400.52(c)(2)Documentation was not provided notating the completion of training of abuse prevention detection and reporting for the 2021 training year for staff 2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. Staff 2 is currently on leave and will receive the required 2022 training upon her return. 07/23/2022 Implemented
6400.52(c)(3)Documentation was not provided notating the completion of training of individual rights for the 2021 training year for staff 2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. Staff 2 is currently on leave and will receive the required 2022 training upon her return. 07/23/2022 Implemented
6400.52(c)(4)Documentation was not provided notating the completion of training of recognizing and reporting incidents for the 2021 training year for staff 2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. Staff 2 is currently on leave and will receive the required 2022 training upon her return. 07/23/2022 Implemented
6400.52(c)(5)Documentation was not provided notating the completion of behavioral supports for the 2021 training year for staff 2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. Staff 2 is currently on leave and will receive the required 2022 training upon her return. 07/23/2022 Implemented
6400.169(d)Prior to June 2022, there is no record of medication administration training for staff 2, The medication trainings provided show that Amelia was medication trained on 6/21/22 but not prior to the aforementioned date. Staff administered medication during the undocumented period.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The agency did not maintain complete records of training for the 2021 training year. The employment of the management person responsible for maintaining training records was terminated however the agency was unable to recreate the records as the originals were not available. 07/01/2022 Implemented
SIN-00189448 Renewal 06/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Not all surfaces were found to be in good repair. The kitchen silverware drawer was found to be jammed in its track, and unable to fully close.Floors, walls, ceilings and other surfaces shall be in good repair. The track was removed and reattached to the interior of the kitchen cabinet using larger fasteners to ensure that the weight of the silverware drawer will not cause the track to become loose in the future thereby allowing the drawer to fully close. Attachment A 06/30/2021 Implemented
SIN-00168390 Renewal 11/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a tacky, sticky substance on the kitchen cabinets.Clean and sanitary conditions shall be maintained in the home. The kitchen cabinets have been cleaned and sanitized. The Program Specialist will monitor the home in the future to insure compliance. Attachment A4 11/25/2019 Implemented
6400.71The landline telephone in individual#1's bedroom did not have emergency numbers listed on or near the telephone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. 71 Emergency telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center have been placed by the landline telephone in individual #1's bedroom. The Program Specialist will monitor the home in the future to insure compliance. Attachment A3 11/21/2019 Implemented
6400.181(e)(9)On individual #1's assessment the documentation of disability was omitted, which did not include medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The documentation of the individual's disability including functional and medical limitations has been added to the Table of Contents of the assessment as the specific information is found in the Lifetime Medical History and Strengths/Needs assessment. This will be completed for all individuals as their assessments become due. Attachment A2 11/25/2019 Implemented
6400.181(e)(12)For individual#1, recommendation for specific areas of training, programming and service was left blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Program Specialist has been instructed to complete the section of the assessment pertaining to recommendations for specific areas of training and programming prior to distributing the assessment to the team members, rather than waiting until the meeting and recording the consensus of the team with regard to approved outcomes. Attachment A1 11/25/2019 Implemented
SIN-00117744 Renewal 07/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(j)Staff #1's record did not contain the previous medication administration documentation. Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The Medication Trainer for the review period is no longer employed by the agency and the records which she generated for Medication Training could not be located. The current Medication Trainer preserves these records by scanning copies into the agency's computer system in addition to maintaining paper files. Attachment B3 07/14/2017 Implemented
6400.163(c)Individual # 1's medication reviews occurred on 07/28/2016 and 02/14/2017. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Healthcare Coordinator has been instructed to review the 90 day psychotropic medication review form to insure that there is an entry for the next appointment date that falls within the ninety day requirement. If this is not the case, the Healthcare Coordinator will contact the physician's office to schedule the next appointment and enter the date and time into the master appointment calendar. In the event of a physician's cancellation of a scheduled appointment, the cancellation will be documented on the calendar and the next available appointment will be scheduled. A review of all individuals who are taking psychotropic medications indicate that no one is currently out of date for these reviews. Attachment B2 08/04/2017 Implemented
6400.181(e)(12)Individual # 1's annual assessment dated 04/18/2017 did not document recommendation in the areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Program Specialist has been instructed to complete the section of the assessment pertaining to recommendations for specific areas of training and programming prior to distributing the assessment to the team members, rather than waiting until the meeting and recording the consensus of the team with regard to approved outcomes. Attachment A1 07/19/2017 Implemented
6400.213(1)(i)Individual # 1's record did not document identifying marks.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.Individual 1's vital sheet was updated to document that there are no identifying marks. All individual records were reviewed and found to have documentation of any identifying marks or the absence of such. Attachment B1. 08/14/2017 Implemented
SIN-00142596 Renewal 08/21/2018 Compliant - Finalized
SIN-00089991 Renewal 03/01/2016 Compliant - Finalized
SIN-00073069 Renewal 12/01/2014 Compliant - Finalized
SIN-00053912 Renewal 12/03/2013 Compliant - Finalized
SIN-00042169 Renewal 01/04/2013 Compliant - Finalized
SIN-00047440 Renewal 01/04/2013 Compliant - Finalized