Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228713 Renewal 06/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)EZ Soap foam hand soap found in dispenser wall unit in shared bathroom-call poison control-removed during inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. 1. This area of non-compliance was corrected in the presence of licensing staff during the inspection. 2. The Program Coordinator or Program Director will complete site inspections on all other programs by 9/30/2023 and document compliance with 55 PA Code Chapter 6400.62(a) on Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed [Attachment #2] 09/30/2023 Implemented
6400.64(a)Exterior of home in need of power wash/painting.Clean and sanitary conditions shall be maintained in the home. 1. The maintenance department power washed the home on 7/20/2023. [Attachment #4] 2. The Program Coordinator or Program Director will complete site inspections on all other programs by 9/30/2023 and document compliance with 55 PA Code Chapter 6400.64(a) on the Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed [Attachment #2] 09/30/2023 Implemented
6400.65No window/operable mechanical ventilation in hall bathroomLiving areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. 1. The maintenance department replaced the hall bathroom exhaust fan on 6/28/2023. [Attachment #6] 2. The Program Coordinator or Program Director will complete site inspections on all other programs by 9/30/2023 and document compliance with 55 PA Code Chapter 6400.65 on Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed [Attachment #2] 09/30/2023 Implemented
6400.82(f)No toilet paper in bathroom-replaced during inspectionEach 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. 1. Toilet paper was placed in the bathroom on 6/28/2023 and observed by licensing staff. 2. The Program Coordinator or Program Director will complete site inspections on all other programs by 9/30/2023 and document compliance with 55 PA Code Chapter 6400.82(f) on Modified Licensing Inspection Instrument Score Sheet. All areas of non-compliance will result in a maintenance request to be fixed [Attachment #2] 3. In order to prevent reoccurrence, the Program Director retrained the Program Coordinators on 55 PA Code Chapter 6400.82(f) on 9/5/2023. [Attachment #1] 09/30/2023 Implemented
SIN-00189869 Renewal 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(t)The Individual Rights packet dated 04/14/2021, which was reviewed with and signed by individual #1, does not enumerate the right to access food at any time. It cannot be reasonably determined whether this individual right was reviewed with the individual. [Note: Provider-Wide Issue]An individual has the right to access food at any time.1. Program Directed update the Individual Rights Policy on 7/19/2021 to include right to access food. [Attachment #9]. The Program Specialist reviewed the Individual Rights Policy with individual #1 on 9/10/2021. [Attachment #10] 2. The Program Specialist Supervisor will review the new Individual Rights Policy with all consumers by 9/24/2021. 09/16/2021 Implemented
SIN-00119031 Renewal 07/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Individual #1's medication log was intialed for the calcium/magnesium tablet on 7/20/17 at 6:00pm, but the inspection occurred at approximately at 11:00am on 7/20/17.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. 1. A plan to fix the immediate problem. a. Target Date: 8/15/2017 - The Program Coordinator will sign the staff person up to be retrained on Medication Administration MAR Documentation. Documentation of the retraining will be completed on the agency Training Registration form. See ATTACHMENT #1. b. Target Date: 9/15/2017 - All consumers' July 2017 completed MARs will be reviewed using the MAR Review Checklist by a Practicum Observer/Medication Administration Trainer to evaluate compliance to 55 PA Code Chapter 6400.164 (a). See ATTACHMENT #2 for an example. All non-compliant practices will be reviewed with the employee using the agency Training Registration Form and corrected. 2. A plan to prevent future occurrences. a. Target Date: 8/10/2017 - A Medication Trainer will document a retraining on an agency Training Registration Form for all Practicum Observers on how to complete a MAR Review Checklist. See ATTACHMENT #3 b. A Practicum Observer will review all consumers' completed MARs for accuracy. All non-compliant practices will be reviewed with the employee using the agency Training Registration Form and corrected. 3. Target Date: 8/10/2017 - All Medication Trainers and Practicum Observers responsible for this plan of Correction will be trained in their responsibilities. See ATTACHMENT #4. 09/15/2017 Implemented