Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227010 Renewal 06/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(14)For individual 3, the assessment does not report on her functional ability to swim, only that if she is near bodies of water, she requires staff assistance. The ISP reports that she enjoys being in a pool but does not swim well and would need a staff person in the water with her.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. On 7/7/23 annual assessment form used by agency was updated to include a statement under water safety that requires the assessor to answer "can the individual swim (circle one) yes or no". On 7/11/23, an addendum was added to individual 3's assessment which states that NO she cannot swim. The addendum was mailed to the individual and her supports coordinator along with a letter explaining that an addendum was made 07/11/2023 Implemented
6400.217Consent for information release was not found in individual 3's record.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. On 7/11/23, the director of quality development met with individual 3 to complete consent to release information forms for her physician office¿s and supports coordinator. Releases are now in her file for Ganley Podiatry, Sam Inc, Dr. Wolf-Shatz, Dr. Marta, Bryn Mawr Periodontics, and Dr. Kusmerick. 07/11/2023 Implemented
6400.24Individual 3's controlled medication pill count for their vimpat medication was incorrect. The log indicated 25 pills were left; 26 pills were found.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Agency nurse was contacted at 11 and gave the ok for KF to have medication administered late, which corrected the count. The staff who administered the medication was given additional training on the importance of not signing out a medication until it is administered. 10/01/2023 Implemented
6400.32(r)Individuals 3 and 4 do not have locking mechanisms on their bedroom doors.An individual has the right to lock the individual's bedroom door.Locks were installed on individual 3 and 4's bedroom doors. 10/09/2023 Implemented
6400.34(a)There was no signed copy of individual 3's rights found in the record.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The director of Quality Development met with individual 3 on 7/11/23 to inform and explain to her the individual rights and the process to report a rights violation. A copy of the individual rights was signed by the individual and the DQD. The form was filed in the individual 3'S record. 07/11/2023 Implemented
6400.163(h)Individual 3's PRN 325mg acetaminophen was kept beyond its expiration date of 5/13/23.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Individual 3's expired Tylenol was disposed of by the CEO on 6/30/23 in the drug take back unit at CVS pharmacy at 1200 w main st, Norristown, PA 19401. 06/30/2023 Implemented
6400.167(a)(1)Individual 3 was not administered their 8AM vimpat dosage on 6/30/23. A medication error incident must be entered for the missed dosage.Medication errors include the following: Failure to administer a medication.Medication error was entered in EIM on 7/2/23 at 1:08 pm. Agency Nurse was contacted and medication was administered late. 07/02/2023 Implemented
SIN-00207670 Renewal 06/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the main hall shower measured at 125.2 degrees Fahrenheit. Water was adjusted immediately following inspected and adjusted below 120 degrees within 24 hours. Hot water temperatures in bathtubs and showers may not exceed 120°F. The home is equipped with a mixing valve to prevent the temperature from exceeding 120 degrees Fahrenheit. This mixing valve is located in the utility area of the home. The hot water pipe that supplies the main bathroom runs from that valve up and through a crawl space and back down through a wall to the bathroom fixtures. The crawl space is not temperature controlled and permits the plumbing pipe to be heated in the summer months thereby increasing the water temperature above the limit regulated by the primary mixing valve. The water heater was adjusted immediately by maintenance personnel to a level which did not result in the water being heated in the crawl space to exceed 120 degrees Fahrenheit. 07/22/2022 Implemented
SIN-00189450 Renewal 06/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions were not maintained throughout the home. A black material consistent with mold or mildew was found caked along the joint of the dishwasher door, on both the door itself and around the bottom of the interior of the machine. Clumped brown material consistent with dirt or grime was also found around the plastic lining/flooring of individual Elizabeth Wolfe's shower.Clean and sanitary conditions shall be maintained in the home. The dishwasher was cleaned and sanitized. The shower floor was cleaned and sanitized. Attachment F 06/29/2021 Implemented
6400.66The property does not have a light on the exterior of its front porch. There is a light inside the property's vestibule, but it was non-operational at time of inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light fixture in the vestibule has been replaced and a new outside light was installed. Attachment G 06/29/2021 Implemented
6400.67(b)Not all surfaces were found to be free from hazards. A pipe was found to be leaking in a utility closet that is accessible from the side porch. A large pool of water was collected outside of the door, and when noted, the agency's response was to temporarily turn the house's water off and turning it on again as needed while waiting for a repair. Water must not be mitigated or restricted in any way. Floors, walls, ceilings and other surfaces shall be free of hazards.The leaking relief valve was replaced on 6/25/21. Attachment H 06/25/2021 Implemented
6400.68(b)Hot water in the primary bathroom was found to exceed 120 degrees. Initial readings of the temperature ranged between 123 and 125 degrees in the shower, and 130 degrees in the sink. It was fixed during inspection and at a follow-up reading, the water in the shower was found to be 114 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. As noted in the citation, the water temperature was adjusted during the inspection. The hot water mixing valve was serviced on 6/24/21. Attachment I The water temperature in all homes has been checked and found to be below 120 degrees Fahrenheit. 06/24/2021 Implemented
6400.141(c)(14)Individual #1's 12/8/20 physical exam did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1¿s annual physical exam has been updated by her physician to include information pertinent to diagnosis in case of emergency. Attachment J All Individual records have been reviewed to ensure that the physical form is fully completed. 07/14/2021 Implemented
6400.217It could not be determined that Individual #2's file contained a signed consent for the release of information as one was not observed at time of inspection.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Individual #2 has completed a signed consent for the release of information. ATTACHMENT K All individual records have been reviewed and consents have been updated as needed. 07/20/2021 Implemented
SIN-00168394 Renewal 11/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(f)Individual#1's undergarments are housed in a hall closet outside of the bedroom., not giving the individual immediate access. According to staff, it is due to the individual stuffing said items into the toilet. No documentation of same was provided during inspection.An individual has the right to receive, purchase, have and use personal property. #1's undergarments have been relocated to her bedroom dresser The Program Specialist will monitor the home in the future to insure compliance. Attachment B7 11/25/2019 Implemented
6400.46(g)It could not be determined if staff member #1 was trained in fire safety on 8/28/19 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). The Annual Fire Safety Training was conducted by the local fire department on 8/28/19 and the training certificate was signed by a representative of the Lower Providence Fire Department as has been the providers practice for over twenty years. Documentation includes the signed training certificate (Attachment B4), a check payable to Lower Providence Fire Department in consideration of the training (Attachment B5) and an excerpt from the Fire Department's website showing that the person signing the certificates is a member of that Department (Attachment B6). The Provider shall seek out other fire safety experts to conduct its annual training if the Local Fire Department is no longer an acceptable source of the training. 11/20/2019 Implemented
6400.82(f)Individual#1's bathroom did not have soap, a trash can, or paper towels. Staff states the individual stuffs all in the toilet. Individual support plan was not provided to validate during inspection.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. Soap, trash can and paper towels have been added to Individual #1's bathroom. The Program Specialist will monitor the home in the future to insure compliance. Attachment B3 11/25/2019 Implemented
6400.112(e)There was no sleep fire drill held every six months. Records show a sleep drill was held on August 3, 2018 and subsequent drill was conducted on April 9,2019.A fire drill shall be held during sleeping hours at least every 6 months. The Healthcare Coordinator shall track the drills each month and makes certain they are turned in no later than the 15th of every month. In conjunction with doing that the Healthcare Coordinator will insure that each site has the correct form with the Sleep Drill option and on the months of the sleep drills the correct form is submitted. Attachment B2 11/20/2019 Implemented
6400.168(d)The last medication administration training was completed 5/22/18 for staff member#1. There was no documentation found in the record for the completion of the annual medication administration practicum training.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Staff#1 has had four additional Medication Observations and Online review of Lessons 7 and 8 from the Medication Administration Training Program. The Medication Trainer has developed a chart with initial medication training, MAR review, and practicum dates due going forward. This chart will coincide with Google Calendar so that notifications will be provided as these dates are coming due. Attachment B1 02/14/2020 Implemented
SIN-00117748 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 C4 07/14/2017 Implemented
6400.64(a)There was rust found in the bathtub and a black substance consistent with mildew found along the outside perimeter of the tub.Clean and sanitary conditions shall be maintained in the home. The rust in the bathtub has been removed and the tub has been repaired and recaulked. Attachment C3 08/14/2017 Implemented
6400.67(a)A loose and detached piece of carpeting was located between the living room and family room.Floors, walls, ceilings and other surfaces shall be in good repair. A threshold has been installed in the doorway to eliminate the trip hazard between the two carpets. Attachment C2 07/19/2017 Implemented
6400.82(d)The door was missing from Individual # 1's private bathroom.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger.Individual 1's ISP has been updated to indicate that the absence of a door in Individual 1's private bathroom is not a privacy concern and the team recommends that the entrance to this bathroom remain unobstructed. Attachment C1 08/11/2017 Implemented
SIN-00089995 Renewal 03/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was not completed 3 to 6 months before the expiration of the license.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency completed the self assessment in February 2016, six weeks after the expiration of the 2015 license. The agency shall complete a self assessment of all locations by September 30, 2016 which shall be within 3 to 6 months of the expiration of the current license ( 12/31/16). 09/30/2016 Implemented
6400.68(b)The hot water temperature measured in the bathroom shower was tested at 123.4 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. The mixing valve that regulates the water temperature throughout the home was replaced with a new one. 03/07/2016 Implemented
6400.76(a)A leather recliner located in the family room was found to have peeling paint on both arms and the back of the chair. Furniture and equipment shall be nonhazardous, clean and sturdy. The recliner was removed from the home and disposed of. 03/11/2016 Implemented
SIN-00073074 Renewal 12/01/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's shower contained a black substance consistent with mildew where the shower wall meets the base of the shower.Clean and sanitary conditions shall be maintained in the home. The shower was cleaned and disinfected. See attached photos. Supervisors were instructed to monitor the homes for cleanliness and follow up to insure correction on a weekly basis. 12/03/2014 Implemented
6400.67(a)Individual #1's bathroom was missing one inch tiles at the base of the shower stall.Floors, walls, ceilings and other surfaces shall be in good repair. The base of the shower was repaired with the installation of a threshold strip over the damaged area. See attached photos. Supervisors were instructed to monitor homes for needed repairs and report any issues promptly. The Program Specialist will visit the home weekly to ensure that all areas of the home are clean and in good repair. 12/03/2014 Implemented
SIN-00047445 Renewal 01/04/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)There was no sleep drills held between the months of 5-1-12 to 12-1-12.(e) A fire drill shall be held during sleeping hours at least every 6 months. : Hap Inc. currently conducts sleep drills every 3 months to provide additional practice in exiting during sleep time and avoid missing this regulation. The site in question conducted a sleep drill when the clients were asleep at 9:30pm. This time was not accepted as a time most people would typically be sleeping. A more appropriate time to conduct a sleep drill is between the hours of 11:00pm and 5:00am. All Hap Inc. employees will be instructed by supervisors and at the annual safety trainings of this time period. In additional the fire drill form will have ¿sleep drill¿ noted on the form when a drill is a sleep drill. New employees will be instructed of this procedure during orientation. 01/15/2013 Implemented
SIN-00142600 Renewal 08/21/2018 Compliant - Finalized
SIN-00053917 Renewal 12/03/2013 Compliant - Finalized