Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215965 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66On 12/7/22 at 1:13 PM, the ceiling light fixture near the basement door leading into the attached garage in the basement of the home was inoperable. There is not another source of light in this area. On 12/7/22 at 1:16 PM, ceiling light fixture in the garage of the home did not have a light bulb. There is not another source of light in garage.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The maintenance department assessed and fixed the ceiling light fixture in the basement leading to the garage. It is now operable. A light bulb was place in the ceiling light fixture in the garage and now there is light. 12/13/2022 Implemented
6400.101On 12/7/22 at 1:10 PM, the basement side of door between the basement and the garage had a key locking mechanism and dead bolt obstructing egress from the garage when engaged. There is not a man-door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The maintenance department changed the lock so the exit between the basement and the garage was unobstructed. Discussion was held with the Agency Program Specialists and Maintenance person regarding this regulation. 12/13/2022 Implemented
SIN-00182847 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The door at the front of the home was used as the exit route in the fire drills held from 11/26/2019 to 1/14/2021. The home has two exit routes.Alternate exit routes shall be used during fire drills. A fire drill was conducted on 2/16/2021 with staff on duty and individuals using the back door entrance. The fire drill was documented and received by the program specialist to review and sign. Going forward, all monthly fire drills will be completed by staff, reviewed and signed by the program specialist, and then reviewed and signed by the program director to ensure that both exits are being used during the completion of the fire drill. All staff were trained on regulation 6400.112(f). Supporting documentation attached. 02/16/2021 Implemented
6400.52(c)(2)Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not encompass 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 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.Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(2). Supporting documentation attached. 02/15/2021 Implemented
6400.52(c)(3)Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(3). Supporting documentation attached. 02/15/2021 Implemented
6400.52(c)(4)Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include recognizing and reporting Incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(4). Supporting documentation attached. 02/15/2021 Implemented
6400.52(c)(6)Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include the implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(6). Supporting documentation attached. 02/15/2021 Implemented
SIN-00164027 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin testing completed 9-11-19, and the previous Tuberculin skin testing was completed 8-23-17.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The Program Director is responsible to train the Program Specialist on 55 PA Code Chapter 6400.141(c)(6). The program specialist in turn will train all direct care staff on this regulation. A chart was created to monitor due dates for the tuberculin skin test by Mantoux method. The Program Specialist will review these dates on a monthly basis to ensure time frames are met and will share this information with Direct Care staff. The Program Director will continuously monitor the dates of individual physicals and T.B. skin tests. Laurel House will make every effort to schedule the annual physical and TB skin test during the same visit so that keeping track of both dates will be more efficient. Supporting documentation attached. [Training documentation submitted to the Department, 3 program specialist and 11 staff were educated on "55 PA code Chapter 6400.141c6, stating that the Mantoux TB will be done with in the correct timeline." As per Program Director, all staff were educated on agency process for scheduling annual medical appointments to ensure timely completion of Tuberculin skin testing. At least quarterly for 1 year, the Program Director shall audit a 10% sample of Individuals' Tuberculin skin testing and the aforementioned tracking documentation to ensure timely completion of Tuberculin skin testing. (DPOC by AES,HSLS on 10/18/19)] 10/16/2019 Implemented
SIN-00124741 Renewal 11/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Thermometer was added to first aid kit. Contents of first aid kit to be checked every month by staff. Direct care staff will notify the program specialist of the contents of the first aid kit. Training on regulation 6400.77(b) was given to direct care staff and the program specialist. Physical site section on the LII to be completed every three months by the program specialist. Program director will verify that this was completed. Supporting documentation attached. [Within 30 days of receipt of the plan of correction, the program director or designee shall educate all staff persons working in community homes of the agency procedures to restock and replenish required items in first aid kits to ensure first aid kits contain all required items at all time. Documentation of trainings shall be kept. Documentation of verifications of the aforementioned audits by Program Specialist shall be kept. (AS 12/12/17)] 11/17/2017 Implemented
6400.80(b)Across the middle of the driveway in the front of the home there was an area eleven feet long by four feet and three inches wide of dirt and crumbling asphalt that was uneven and recessed approximately six inches posing a falling and tripping hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Outside walkway at 401 Morgantown Street was completed on 11/17/17. Training was given to direct care staff and program specialist on regulation 6400.80(b). Physical site section on LII to be completed every three months by the program specialist. Program director to review the LII once it is completed and supporting documentation is attached. [Aforementioned training occurred on 12/6/17 for 4 attendee with the program director as the trainer. Within 30 days of receipt of the plan of correction, the program director shall educate all staff person of the agency's procedures for monitoring, reporting, maintaining and completing necessary work to ensure the outside of the building and yard or grounds are well maintained, in good repair and free from unsafe conditions at all time. Documentation of the training shall be kept. (AS 12/12/17)] 11/17/2017 Implemented
SIN-00144563 Renewal 10/31/2018 Compliant - Finalized