Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225301 Renewal 05/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Documentation of PA state residency or FBI criminal record check was not provided for staff 1, whose hire date is listed as 3/27/23.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. HR manager and Director of Talent Acquisition will train all staff on requirements for credentials for staff required by ODP. 08/11/2023 Implemented
6400.21(a)PA criminal background check documents were not provided for all new hires EXCEPT staff 2, 3, 4, and 5.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. HR manager and Director of Talent Acquiaition will train all staff on requirements for credentials for staff required by ODP 08/11/2023 Implemented
6400.112(d)The evacuation time on 8/23/22 was recorded as "15 min." which exceeds the allotted evacuation time. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Individual was trained by fire safety expert in November 9th, 2022 on evacuation procedures 08/11/2023 Implemented
6400.112(h)In June and May of 2022 the fire drill record did not list the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Division Manager will conduct a training on completion of fire drill form 08/11/2023 Implemented
6400.52(a)(1)The provided training records did not establish if the required (staff) 24hrs was met.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.IDD residential director and Compliance Coordinator will meet with learning and staffing development to provide a monthly tracking report on all ODP required trainings 08/11/2023 Implemented
SIN-00205349 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drills held during months of Sept, Oct, Nov, Dec 2021 all state "2 mins" for the evacuation time.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Fire drill form is being updated to capture the missing information and will begin to be used on July 1, 2022. 07/01/2022 Implemented
6400.141(c)(6)There is no current TB test on file for individual #4.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. An appointment was made for the individual for a PPD to be placed on 06/07/2022. 06/07/2022 Implemented
6400.141(c)(7)There is no current gynecological exam on file for individual #4.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Gynecological exam is scheduled for the individual. This was scheduled at the time of the audit and the information provided to the auditor. The appointment is 06/17/2022. 06/17/2022 Implemented
6400.142(d)The Dental exam dated 2/22/22 for individual #4 did not indicate that a cleaning was performed at the appointment.The dental examination shall include teeth cleaning or checking gums and dentures. Dental exam is scheduled for the individual and the information was provided to the auditor during the inspection. The appointment is 06/04/2022 to remove her braces and the cleaning appointment is 06/06/2022. 07/01/2022 Implemented
6400.166aRegarding Individual #4's medication review: Medication acetaminophen was found in the individual's medication container as a prescribed PRN, but not listed on the MAR.Notification of an adverse reaction to a medication may be made to the prescribing certified registered nurse practitioner (CRNP) when the medication was prescribed by a CRNP as authorized under 49 Pa. Code Chapter 18, Subchapter C (relating to certified registered nurse practitioners) and Chapter 21, Subchapter C (relating to certified registered nurse practitioners). The MAR was corrected and the pharmacy contacted to ensure their information is accurate. 07/01/2022 Implemented
6400.181(a)The assessment for individual #4 dated 1/16/22 was not completed up to regulatory standards. -The regulations state that the assessment cannot be vague or non-specific. It also states an assessment is to be meaningful accurate and useful. As such the provided assessment did not provide thorough documentation of: - Functional strengths - Likes and dislikes of the individual - Ability to safely avoid poisons - Ability to evacuate in the event of a fire - A lifetime medical history Additionally there is no documentation showing that the assessment was sent to the team 30 days before the ISP meeting. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The assessment was updated. An annual ISP has not been completed as her admission was in December 2021. 07/01/2022 Implemented
6400.163(d)Regarding Individual #4's medication review: The medication Loratadine 10mg tablet is listed on the MAR as a PRN, but was not found with the individual's medication containerPrescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The PRN medication was filled and is now in the medication container. 06/01/2022 Implemented
6400.165(g)There is no documentation that individual #4received psychiatric medication reviews every 90 days.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.The individual is prescribed her medications from her PCP. She does see her PCP regularly for refills. The appropriate paperwork will be sent to the PCP so they are able to complete the requirements for psychiatric checks until a psychiatrist is found. 07/01/2022 Implemented
6400.166(a)(4)Regarding Individual #4's medication review: Medication Deso/ethinyl .01mg tablet was so named on the blister pack; the MAR identifies the medication as Volnea .01mg tablet.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The MAR was corrected and the pharmacy contacted to ensure their information is accurate. 07/01/2022 Implemented
6400.166(b)Regarding Individual #4's medication review: Medications Guanfacine 1mg tablet and Deso/ethinyl .01mg tablet (both 8AM doses) were not signed off on the MAR; the blister packs indicated that they had been given.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff will be retrained on completing the electronic MAR by 07/01/2022. 07/01/2022 Implemented
6400.213(1)(i)There was no current dated photograph present in the file of individual #4.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual now has a current photo as part of the record. 05/04/2022 Implemented
SIN-00187583 Renewal 05/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)There was no fire extinguisher located in the kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). A fire extinguisher with a minimum2A-10BC rating was installed in the kitchen. 05/10/2021 Implemented
SIN-00115556 Renewal 06/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)THE CURRENT PHYSICAL EXAM FOR INDIVIDUAL #1 WAS DATED 08/08/2016 AND THE PREVIOUS YEAR WAS DATED 05/21/2015 WHICH IS MORE THAN 1 YEAR. An individual shall have a physical examination within 12 months prior to admission and annually thereafter. A appointment book is presently used by the Coordinator/Supervisor to schedule & record up-coming appointments. This appointment book is reviewed on a weekly basis so that time frames are not exceeded, This weekly review has also been added to the Coord./Sup. schedule. See attached 07/07/2017 Implemented
6400.181(c)THE ANNUAL ASSESSMENT DATED 04/12/2017 FOR INDIVIDUAL #1 DID NOT IDENTIFY THE SOURCES OF INFORMATION USED TO DEVELOP THE ASSESSMENT. The assessment shall be based on assessment instruments, interviews, progress notes and observations. The source information used to develop the assessment have been added for the 4/21/17 assessment--interviews, progress notes and observations. The Coordinator & Supervisor will assure that this information is always included on the assessment. see attached 06/05/2017 Implemented
6400.181(e)(5)INDIVIDUAL #1'S ASSESSMENT DATED 04/12/2017 DID NOT LIST ABILITY TO SELF-ADMINISTER MEDICATION.The assessment must include the following information:  The individual's ability to self-administer medications.An outdated assessment form was used for the 4/12/17 assessment. The assessment was completed on the updated form and now includes self-administering ability. All Coordinators will assure that the most current forms are used. see attached 06/30/2017 Implemented
6400.181(e)(7)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/12/2017 DID NOT LIST KNOWLEDGE OF HEAR SOURCES. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. An outdated assessment form was used for the 4/12/17 assessment. The assessment was completed on the updated form and now includes knowledge of heat sources.. All Coordinators will assure that the most current forms are used. see attached 06/30/2017 Implemented
6400.181(e)(8)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/12/2017 DID NOT LIST ABILITY TO EVACUATE IN A FIRE. The assessment must include the following information: The individual's ability to evacuate in the event of a fire. An outdated assessment form was used for the 4/12/17 assessment. The assessment was completed on the updated form and now includes the ability to evacuate in a fire.. All Coordinators will assure that the most current forms are used. see attached 06/30/2017 Implemented
6400.181(e)(14)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/12/2017 DID NOT DOCUMENT ABILITY TO SWIM AND KNOWLEDGE OF WATER SAFETY. 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. An outdated assessment form was used for the 4/12/17 assessment. The assessment was completed on the updated form and now includes the ability to swim and water safety. All Coordinators will assure that the most current forms are used. see attached 06/30/2017 Implemented
6400.181(f)THE RECORD FOR INDIVIDUAL #1 DID NOT DOCUMENT THAT THE ASSESSMENT WAS SENT TO THE S.C. AND TEAM MEMBERS AT LEAST 30 PRIOR TO THE ISP MEETING. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Coordinator hand-delivered the current assessment to the Supports Coordinator on 4/20/17 however, she did not have the attached form signed at that time for the ISP meeting scheduled for 5/24/17. The form was signed on 8/11/17 attesting to the fact that the assessment actually was given to the SC at least 30 days prior to the ISP meeting. see attached 08/11/2017 Implemented
6400.184(c)THE RECORD FOR INDIVIDUAL #1 DID NOT CONTAIN A SIGN-IN SHEET OR OTHER VERIFICATION OF ATTENDANCE AT THE ANNUAL ISP MEETING. A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.THE SIGN-IN SHEET FOR INDIVIDUAL #1 is attached. It had been filed in the wrong section in her file during the Licensing inspection. The Coordinator/Supervisor will assure that all information is filed in the appropriate place. see attached 06/05/2017 Implemented
SIN-00090729 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff 14's previous medication training was completed on 12/16/14 and the annual practicum for 2015 was not completed. "Repeated Violation-10/30/14, et al" In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Per instructions from state inspectors, remediation would need to occur for this staff to give meds. On 1/27/ 16-- 4 MARs were completed with passing results. On 1/26/16-- 2 practicum observations were completed for this individual with passing results. See supporting documents .[The Program Director will develop an auditing document to note the date of each staff's medication administration training and the date of the annual practicums, within 10 days of receipt of this plan of correction. The Program Director will review the auditing document at least bi-annually to ensure only trained staff are administering medications, starting immediately. SW 3.8.17] 01/27/2016 Implemented
SIN-00244148 Renewal 05/02/2024 Compliant - Finalized
SIN-00161682 Renewal 08/27/2019 Compliant - Finalized
SIN-00140985 Renewal 06/21/2018 Compliant - Finalized
SIN-00077837 Renewal 10/29/2014 Compliant - Finalized