Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00179472 Renewal 11/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medications to treat symptoms of the psychiatric illness, intermittent explosive disorder. The reviews of medications conducted 9/8/20, 6/9/20, 1/21/20 and 10/22/19 did not include the need to continue the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.On 11/24/2020, the program managers and program coordinators have been retrained on the 6400.165.g regulation if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. A new psychiatric medication review form was created and effective immediately, will be used in addition to the appointment consultation form. All forms will be uploaded to the ECR. The program manager and program coordinator will review the appointment documentation to ensure that the scheduled appointment is within the 3-month time frame, includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. An additional review will be completed by utilizing a monthly clinician report in the ECR and ongoing audits will be conducted by the quality team. Supporting documentation of the retraining of the program managers and program coordinators, the new psychiatric medication review form and the example of the ECR monthly clinician report will be submitted. 11/25/2020 Implemented
SIN-00108703 Unannounced Monitoring 02/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
Article X.1007An employee or an administrator is required to immediately report suspected abuse of a resident served in the home in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. 10225.701-10225-707) and 6 pa. Code 15.21-15.27 (relating to reporting suspected abuse) and comply with the requirements regarding restrictions on staff persons. On 10/18/16, Direct Service Worker #1 was informed of an allegation of physical abuse involving Individual #1. The incident was reported to Area Agency on Aging, Protective Services on 11/22/16.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Any allegation of abuse, neglect or exploitation that is not clearly reportable to APS will be double checked with the Human Services Program Specialist at DHS. Should the DHS determination be different from the Mainstay determination, Mainstay will defer to the decision of DHS as per process outlined by Individual #1 letter effective Nov 1, 2015 (to be submitted). Mainstay's policy will be changed to reflect the process outlined (to be submitted). All coordinators will be trained in new process by Dave Cochran, Director of Residential Services, by March 3, 2017 (documentation to be submitted). [Immediately, the Director of Residential Services will review the Adult Protective Services (APS) section on DHS.pa.gov to providers to human services licensing: http://www.dhs.pa.gov/citizens/reportabuse/dhsadultprotectiveservices/index.htm#.Vjow2FUo6mQ to develop a training and to change policies to ensure reporting in accordance with APS law. Within 60 days of receipt of plan of correction and continuing at least annually, the Director of Residential services shall coordinate and implement a training of all staff person to ensure timely reporting in accordance with APS law. Documentation of training shall be kept. (AS 2/24/17)] 03/03/2017 Implemented
SIN-00230507 Renewal 09/06/2023 Compliant - Finalized
SIN-00119660 Renewal 08/14/2017 Compliant - Finalized
SIN-00069642 Renewal 09/10/2014 Compliant - Finalized