Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00165761 Renewal 10/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The Shower floor in the handicap accessible bathroom had dirt and grime buildup.Clean and sanitary conditions shall be maintained in the home. 1. The Property Manager will obtain bids to have the shower replaced by 1/15/2020. See attachment #1. The shower was cleaned but it has been determined it is stained. 2. The Program Coordinator will complete site inspections on all other programs by 1/15/2020 and document compliance with 55 PA Code Chapter 6400.64 (a) on a Modified Self-Assessment Licensing Inspections Instrument. See Attachment #3. All areas of non-compliance will result in immediate corrective action and staff retraining. 3. In order to prevent reoccurrence, The Program Coordinator/Property Manager will conduct site inspections for each licensed program once a quarter. See attachment #8. All areas of non-compliance will result in a maintenance/supervisor request to be corrected through an agency electronic submission. See attachment #6 (Sample). All areas of non-compliance will result in a immediate corrective action and staff retraining. 4. The Program Director trained staff responsible for the Plan of Correction and corresponding regulations on 12/13/2019. See Attachment #5. 01/15/2020 Implemented
SIN-00096425 Renewal 04/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Through staff interviews, it was determined fire drills are not always unannounced. An unannounced fire drill shall be held at least once a month. 1. Previous non-compliant practices of conducting an unannounced fire drill each month cannot be corrected. 2. In order to prevent reoccurrence, the Program Coordinator retrained all Program Supervisors (responsible for conducting all fire drills) on 4/14/2016 on 55 PA Code Chapter 6400.112(a) ¿was an unannounced fire drill held at least once a month.¿ See Attachment # 2. 3. The Program Coordinator will interview each staff present during a fire drill at each program by 9/30/2016 to track compliance. This will be documented on Attachment #1. 09/30/2016 Implemented
6400.186(c)(4)(iii)Individual # 1's outcomes of "community" and "self-sufficient" were measured by the same strategies implemented during the previous ISP dated 10/19/2014 as well as the current ISP dated 10/19/2015 regardless of progress or lack of progress towards achieving the outcomes. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. 1. The Program Specialist will recommend modification to individual # 1¿s outcome of ¿community¿ and ¿self-sufficient¿ that will reflect different strategies that were implemented in the previous ISP dated 10/19/2015. This will be recommended in the individuals next Quarterly Review completed after 10/18/2016. 2. The program specialist will review all individuals¿ current and previous ISPs outcomes in the program by 9/30/2016. Recommendations will be made on the next quarterly review if strategies implemented from the current and previous ISP were duplicated. 3. In order to prevent reoccurrence, the Program Specialist Supervisor will retrained all Program Specialist on how to properly implement 55 PA Code Chapter 6400.186(c)(4)(iii) by 8/31/2016. See attachment #17. The Program Specialist will conduct a quarterly audit using the Licensing Inspection Instrument Score Sheet section Plan Review and Plan Revision to track future compliance. The Program Specialist Supervisor will track and monitor the audit results. 10/31/2016 Implemented
SIN-00207650 Renewal 06/28/2022 Compliant - Finalized
SIN-00119013 Renewal 07/19/2017 Compliant - Finalized
SIN-00058163 Renewal 01/06/2014 Compliant - Finalized
SIN-00045713 Renewal 02/13/2013 Compliant - Finalized