Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00190758 Renewal 07/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency self assessments notated violations for 6400.141a and 6400.141c4 but did not provide a summary of corrections. The aforementioned regulations pertained to annual physical examinations for individuals.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Program Director contacted the individual's Behavior Consultant regarding Mask Wearing Plan development on 8/18/2021. The individual refuses to wear a mask. The physician's office requires all visitors to wear a mask. 09/30/2021 Implemented
6400.64(a)The dishwasher, stove and range hood were sticky to the touch and had a grease like substance on the surfaces. Staff immediately began cleaning these items during inspection.Clean and sanitary conditions shall be maintained in the home. On 7/27/2021, the Program Director asked the Direct Care Professional present at the site to clean the stove, range hood and dishwasher. The appliances were cleaned. 09/30/2021 Implemented
6400.166(a)(5)The medication administration record (MAR) and the medication label for individual 1's Calcium prescription medication did not match. The strength of medication was different. The MAR indicates Calcium /vitamin tab 600-400 MG and the label on the medication reads Calcium WIT Tab 500-400IU. The prescriber authorized the change in dose however the MAR was not corrected for the month of July 2021.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.On 7/27/2021, the medication record was corrected by the Medical Coordinator. The Medication Record was then placed in the individual¿s book at the site for future use. 09/30/2021 Implemented
SIN-00172045 Renewal 02/05/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment in reference to water temperatures was not assessed in this home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.Self-assessments will be completed 3 to 6 months before the expiration of the license. 06/09/2020 Implemented
6400.66The exterior porch light was found non-operable at time of inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Porch light had its light changed and it is currently functioning. 06/05/2020 Implemented
6400.76(a)Individual #2's bedroom has a clothing armoire door mechanism which was found loose and separating from the door. The medicine cabinet in the bathroom is rusted-out and needs replacing. Furniture and equipment shall be nonhazardous, clean and sturdy. Program Director ordered a new Armoire on 5/26/2020 due to the current Armoire not being repairable. A new medicine cabinet was purchased and installed on 2/25/2020. All Site Supervisors/Program Managers ensured that all furniture and equipment is nonhazardous, clean and sturdy by 2/25/2020. The Self Inspection Tool for 55 Pa. Code Chapter 6400 Regulations will be implemented by the Site Supervisors/Program Managers on a weekly basis as of 6/5/2020.  The completed tool will be submitted to the Program Director/Coordinator for their review.  All areas of non-compliance will be corrected within a week.  The Program Administrator will be informed of all areas of non-compliance and completion plan and date.  Site Supervisors, Program Managers, Program Coordinators and Program Directors will receive training regarding the weekly completion of the Self Inspection Tool by the Program Administrator before or by 6/5/2020. 06/05/2020 Implemented
SIN-00145566 Renewal 11/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)Two of the outside trash receptacles had no lids.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Program Director purchased trash can with lid at Lowes Home Center on 11/08/2018 and placed it at the home. Program Administrator completed training with Program Director and Program Coordinator on 12/12/2018. Program Director/Program Coordinator will complete a Monthly Site Inspection of each home by the 15th of each month. The checklist will indicate if each regulation for the physical site is (a) No violation/not applicable (b) requires corrective action; (c) if applicable when the correction was made. 12/12/2018 Implemented
SIN-00121849 Renewal 09/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)THE SELF ASSESSMENT IS NOT DATED MAKING IT IMPOSSIBLE TO ASSESS COMPLIANCE. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. For the future Self-Assessments, the Program Director will submit the Self-Assessment to the Program Administrator upon completion (3 ¿ 6 months prior to the expiration of the license). The Program Administrator will ensure the Self-Assessment for each site has been dated. The Program Administrator will initial and indicate the date of the review. 11/03/2017 Implemented
6400.181(e)(13)(ii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/18/2017 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF: MOTOR AND COMMUNICATION SKILLS. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The Program Coordinator revised Individual #1¿s Assessment to include progress and growth in the area of motor and communication skills. Attachment #6 6400.181 (13)(ii) -(viii) ¿ Individual #1¿s Assessment The Program Coordinator will revise all individual¿s Assessments by 11/10/2017. All revised Assessments will be reviewed by the Program Director. 11/10/2017 Implemented
6400.181(e)(13)(iii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/18/2017 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF: ACTIVITIES OF RESIDENTIAL LIVING. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The Program Coordinator revised Individual #1¿s Assessment to include progress and growth in the area of activities of residential living. Attachment #6 6400.181 (13)(ii) -(viii) ¿ Individual #1¿s Assessment The Program Coordinator will revise all individual¿s Assessments by 11/10/2017. All revised Assessments will be revised by the Program Director. 11/10/2017 Implemented
6400.181(e)(13)(vii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/18/2017 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF: FINANCIAL INDEPENDENCE.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The Program Coordinator revised Individual #1¿s Assessment to include progress and growth in the area of financial independence. Attachment 6400.181 (13)(ii) -(viii) ¿ Attachment #66400.181 (13)(ii) -(viii) ¿ Individual #1¿s Assessment The Program Coordinator will revise all individual¿s Assessments by 11/10/2017. All revised Assessments will be reviewed by the Program Director. 11/10/2017 Implemented
6400.181(e)(13)(viii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/18/2017 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF: MANAGING PERSONAL PROPERTY.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The Program Coordinator revised Individual #1¿s Assessment to include progress and growth in the area of managing personal property. Attachment #6 6400.181 (13)(ii) -(viii) ¿ Individual #1¿s Assessment The Program Coordinator will revise all individual¿s Assessments by 11/10/2017. All revised Assessments will be reviewed by the Program Director. 11/10/2017 Implemented
SIN-00075889 Renewal 03/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Lint about the size of a gulf ball was found in the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. Staff will be trained to clean out the lint compartment upon completion of each dryer cycle. The Site Supervisor will check the dryers at least weekly. The staff will be trained on the importance of removing lint from the dryer after each use and improve their understanding that lint in a dryer is a potential fire hazard. Staff will be trained on how to remove lint from the dryer after each use. 05/31/2015 Implemented
6400.112(f)The front door was uses as the exit during the fire drill on 3/4/14, 5/7/14, 6/9/14, 7/5/14, 8/3/14, 9/5/14, 10/2/14, 12/6/14, 2/8/15 and 3/6/15. Alternate exit routes shall be used during fire drills. The revised fire drill schedule includes six months of alternate exit fire drills. The drill will be unannounced and only the maintenance director will be familiar with the revised fire drill. The Program Director reviews the fire drill records upon completion to ensure compliance. Staff will receive training on the importance of using alternative exits during the fire drills.receive training on the importance of using alternative exits during the fire drills. 05/31/2015 Implemented
6400.141(a)Individual #1's previous physical examination was dated 7/22/13; the most recent was dated 8/13/14. An individual shall have a physical examination within 12 months prior to admission and annually thereafter. A tickler data base has been developed to include physical examination dates. The Medical Coordinator will be responsible to keep the data base updated and to ensure that physical examinations are completed annually. The Program Director will review the data base monthly to ensure compliance. 06/30/2015 Implemented
6400.141(c)(6)Individual #1's previous PPD screening was dated 2/27/13; the most recent screening was dated 3/18/15. 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. A tickler data base has been developed to include PPD screening dates. The Medical Coordinator will be responsible to keep the data base updated and to ensure that PPD screenings are completed every 2 years. The Program Director will review the data base monthly to ensure compliance. 06/30/2015 Implemented
SIN-00057799 Renewal 02/26/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment form was not dated.(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. In the future, when the Program Director completes the self-assessment of each home, within 3 to 6 months prior to the expiration date of the certificate of compliance (April 1), the document will be dated and submitted to the Program Administrator for review. 01/01/2015 Implemented
6400.181(f)The assessment for individual # 1, dated 1/9/14, was not sent 30 days prior to the ISP meeting of 1/16/14.(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). In the future, the Program Specialist will complete an assessment and provide the assessment to the SC and team members at least 30 days prior to an ISP meeting for the development, annual update and revision of the ISP. 03/31/2014 Implemented
6400.186(a)The quarterly review from 4/13 was not completed for individual # 1.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In the future, quarterly reports will be written every 90 days by the Program Specialist and reviewed by the Program Director. 03/31/2014 Implemented
6400.213(1)(i)The client record for individual # 1 did not have description or identifying marks for this individual.Each individual's record must include the following information: (1) Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The individual's Emergency Medical Sheet (Face Sheet) for the individual's record was updated to include the required information. All individuals' records were updated to include the required information. 03/31/2014 Implemented
SIN-00049234 Renewal 03/14/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(a)There was an Albuterl Sulfate Inhalation Solution 0.083 % in Individual #1's medication box without a pharmaceutical label. (a) The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Albuterl Sulfate Inhalation Solution 0.083 % was purchased through mail order through the individual's insurance. OFP now utilizes the local pharmacy to ensure a label has a pharmaceutical label. The provider will conduct a monthly audit of all individuals medications to ensure that all medications containe the required pharmacy label. 06/30/2013 Implemented