Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237597 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 12/20/23, the hot water temperature at the sink located in the full bathroom on the home's main level measured 131.9 degrees Fahrenheit at 11:25 AM. [Repeated Violation- 1/18/23, et al.]Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. At this residence, the hot water heater was checked by a local plumbing company on 12/21/23 and determined that there was a probably with the vent pipe and recommended that a chimney sweep come and clean the vent pipe. A chimney sweep was contacted and came on 12/22/23 to clean the vent pipe. The water temperature was regulated and determined to be under 120 degrees. In addition, a more accurate thermometer was purchased for the house in order to test the water. 02/16/2024 Implemented
6400.181(e)(12)Individual #1's admission date is 7/31/23. Their initial assessment completed on 9/1/23, did not address or provide any recommendations for specific areas of training, programming, and services. Individual #2's admission date is 4/14/23. Their initial assessment completed on 5/4/23, did not address or provide any recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. For this individual, the assessment has been reviewed again and recommendations included for areas of training, programming, and/or services for the upcoming year. 02/16/2024 Implemented
SIN-00217755 Renewal 01/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 1/18/23, the hot water temperature at the sink of the main-level bathroom measured 126.8 degrees Fahrenheit at 3:11 PM. The hot water temperature at the kitchen sink measured 124.1 degrees Fahrenheit at 3:40 PM.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. At this residence, the temperature on the water heater will be turned down and then rechecked again after 48 hours when the water has had time to circulate through the system and the temperature has been regulated. For all other houses, the maintenance staff will verify the water temperature in the bathrooms and document the temperatures. If there are any temperatures above 120 degrees Fahrenheit, the water heater will be turned down and the water rechecked in 48 hours. 02/03/2023 Implemented
6400.65On 1/18/23, the bathroom located on the main level was discovered with an inoperable exhaust fan at 3:10 PM. This bathroom did not have any windows for ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. At this residence, the exhaust fan in this bathroom will be replaced. The maintenance staff will check the other bathroom in this residence and the bathrooms in all the other houses to ensure that a properly functioning exhaust fan is installed or if not, a window is available for ventilation. 02/03/2023 Implemented
6400.66On 1/18/23, the light outside the basement's only entry door was found non-functional at 3:24 PM. There were no other nearby sources of light observed.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light outside of the basement door is now functioning properly with a bulb in place. However, a new light fixture is going to be installed to replace this outdated fixture. The maintenance staff will ensure outdoor lights at all other houses will be checked as well and any lights that are not functioning properly will be repaired or replaced. 02/03/2023 Implemented
6400.101On 1/18/23, the basement's only outside entry door was observed at 3:22 PM as a blocked egress. Outside access through this entry door requires a sliding latch lock as well as two thumb turn locks to be disengaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The additional locks will be removed from the basement door and a new doorknob with a standard lock will be installed to replace the current doorknob. The maintenance staff will ensure that all exits at this house and all other houses are checked and do not have more than one standard lock. If any inappropriate locks are found they will be removed or replaced immediately. 02/03/2023 Implemented
SIN-00199894 Renewal 02/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was the only evacuation route used when the monthly fire drills were conducted from 3/14/21 through 12/23/21. There are 4 exits in the house.Alternate exit routes shall be used during fire drills. The residential manager has been informed of the need to use various exits when conducting a fire drill in order to ensure all individuals are familiar and comfortable with evacuation procedures no matter where they are located in the home or where the potential fire may be located. 03/04/2022 Implemented
6400.141(c)(9)Individual #1 has not had a prostate examination completed.The physical examination shall include: A prostate examination for men 40 years of age or older. For this individual, the earliest available appointment will be made with the PCP to have the prostate exam completed. [As per agency director, Individual #1 had prostate examination completed on 3/3/2022.(ASE,HSLS on 3/4/22)] 03/04/2022 Implemented
SIN-00185561 Renewal 03/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical examination completed, 10/05/20 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical for this individual has been updated to include the emergency medical information. The physicals for all other individuals will be reviewed to determine that the form is complete and all pertinent information is included. 04/30/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 4/24/20. The rights document did not include the following rights: 6400.32e through 6400.32i, to choose, accept risks, refusal and control the individual's schedule, activities and services, privacy and access to person and possessions; 6400.32n, unrestricted and private access to telecommunications; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, locking doors in bedrooms and in the home, access to food at any time, and making healthcare decisions.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The individual rights form used by the agency has been updated to include all of the rights listed in the regulations. The updated individual rights have been reviewed with this individual and the individual has signed the form in acknowledgement of these rights. [Updated Individual Rights form signed by Individual #1 on 3/17/2021. DPOC by HDKP, HSLS, on 5/4/2021] 04/30/2021 Implemented
6400.46(b)Program specialist #1 most recent annual fire safety training on 01/06/2020.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).For this staff, a fire training was conducted on 3/18/21. The training records for all other staff will be reviewed to determine if the fire training has been done within a calendar year since the previous fire training. 04/16/2021 Implemented
SIN-00168310 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Direct services worker #1, date of hire 5/7/99, had a physical examination, dated 2/25/19; however, the physical examination does not address communicable diseases. This form states that the employee is free from communicable TB. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physicals for these staff will be reviewed by the administrative assistant and any staff that do not currently have a physical form which states they are free from communicable disease will have that part of the physical completed and placed in their file. The Occupational Medicine office which completes our staff physicals has been consulted and has agreed to revise their physical form to include ¿free from communicable disease¿ on the physical form. The administrative assistant will monitor the staff physicals once they are sent to the main office to determine that all areas are complete, including the ¿free from communicable disease¿. The administrative assistant will monitor at least 25% of the staff physicals each month to ensure that they are complete and have the ¿free from communicable disease¿ section on the form and completed. The administrative assistant will be responsible for this plan of correction. 02/29/2020 Implemented
6400.181(a)Individual #1, date of admission 9/20/19, did not have an initial assessment completed within 60 calendar days of admission. Individual #1's initial assessment was completed 12/17/19. 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. An initial admission assessment has been completed. However, it is past the 60 days and there is no way to correct that at this point. All current assessments will be reviewed to ensure they are in compliance with the completion time frame. In the future, an assessment will be prepared for any new admissions and distributed immediately. The assessment will be assigned to specific staff for accountability so that the program staff can go to that person and determine how the assessment is progressing. The staff will be given approximately 45 days to complete the assessment. After this time the assessments will be collected in order for the program staff to review the assessment for thoroughness and return it to the staff if more work is needed. If there is a problem, for whatever reason, with the direct care staff completing the assessment on time the program staff will be responsible for the completion of the assessment within the first 60 days of admission. The program staff will be responsible for this plan of correction and will review all assessments upon completion. 02/29/2020 Implemented
6400.181(e)(4)Individual #1's assessment, dated 12/17/19, does not address the individual's need for supervision. This section of the assessment was blank. The assessment must include the following information: The individual's need for supervision. The assessment for this individual will be reviewed and the area concerning supervision will be completed with the level of supervision required by the individual. The assessments for all other individuals will be reviewed to ensure that they are completed thoroughly. A training will be completed with the staff by 1/31/2020 on how to properly complete an annual assessment. Once the assessments are complete the program specialist is to review the assessment for thoroughness and if any areas are incomplete, they¿re to be returned immediately to the staff to complete them correctly. The Program Specialist Supervisor will monitor 25% of the assessments monthly to ensure that they have been completed correctly and thoroughly. The program specialist and the Program Specialist Supervisor will be responsible for this plan of correction. 02/29/2020 Implemented
6400.181(e)(6)Individual #1's assessment, dated 12/17/19, does not indicate the level of support the individual needs to safely use or avoid poisonous materials. This section of the assessment states "no."The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The assessment for this individual will be reviewed and the area concerning supervision around poisons will be completed with the level of supervision required by the individual. The assessments for all other individuals will be reviewed to ensure that they are completed thoroughly. A training will be completed with the staff by 1/31/2020 on how to properly complete an annual assessment. Once the assessments are complete the program specialist is to review the assessment for thoroughness and if any areas are incomplete, they¿re to be returned immediately to the staff to complete them correctly. The Program Specialist Supervisor will monitor 25% of the assessments monthly to ensure that they have been completed correctly and thoroughly. The program specialist and the Program Specialist Supervisor will be responsible for this plan of correction. 02/29/2020 Implemented
6400.166(b)Rouvastatin Calcium 10 mg with the instructions "take 1 tablet by mouth at bedtime" prescribed to Individual #1 was not initialed as administered at 8:00 PM on 10/29/19. [Repeat violation 1/7/19 et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff member responsible for administering the medication to this individual on the date of the missing documentation will be retrained on the proper medication administration procedure, including signing and initialing the medication administration record. This staff will then be monitored one time per month over the next three months to ensure that they are continuing to follow the correct medication administration procedure. In the future, any staff member who commits a medication error will be retrained and then monitored at least one time per month over the next three months. The medication coordinator, nursing staff, program specialists, and residential managers will complete the retraining and monitoring. The medication coordinator will be responsible for this corrective action and will review 25% of the medication administration records each month to ensure that the medication administration records are being documented correctly. 02/29/2020 Implemented
SIN-00107481 Renewal 01/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)There was not smoke detector located within 15 feet of the bedroom on the first floor near the dining room. There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector was added to the dining room which is outside the bedroom. All homes were checked and are in compliance with having a smoke detector located within 15 feet of the bedroom. During each drill, the person conducting the drill will check all detectors to determine that they are in place and operating. No additional detectors need to be added at this time. A training memo will be sent out to include the review of detectors and the need to document on the Fire Drill form. All managers will be instructed to complete the form by 2/28/2017. 02/16/2017 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was conducted 6/11/16.A fire drill shall be held during sleeping hours at least every 6 months. The specific issue could not be corrected as the year had ended. A schedule will be developed to ensure that sleeping hour drills are conducted at least every six months. The schedule will be presented to the Residential Manager of the home to indicate during which months a sleeping drill needs to occur. The Residential Supervisor will provide the schedule by 2/28/2017. The schedule will begin in March with sleeping drills established. The schedule will apply to all homes. Each manager will submit the Record of the drill to the Main Office each month.. The Residential Supervisor will ensure the sleeping drills were completed as scheduled. All drills should be completed by the 20th of the month. All managers will be trained by the Residential Supervisor by 2/28/2017. [IT IS NOT ACCEPTABLE TO SCHEDULE FIRE DRILLS. The Director will ensure that all fire drill including fire drill conducted during sleeping hours are unannounced to all staff and individuals who are participating in the drills and to ensure the aforementioned schedule is not available to staff or individual who are participating in fire drills. Within 2 weeks of receipt of the plan of correction, the director shall ensure a fire drill during sleeping hours is conducted. (AS 2/23/17)] 02/16/2017 Implemented
SIN-00088997 Renewal 01/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 10:00 AM, the hot water temperature measured at 132.6 degrees fahrenheit at the bathtub in the bathroom on the second floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. Since this was a new water heater, the temperature fluctuated. On January 11, 2016 maintenance corrected the problem and the water temperature was set at 118 degrees. Monthly water checks will be completed by house manager (see submitted Monthly System Check) and quarterly checks will be done by the Safety Committee. We have previously submitted a copy of the Service Invoice from McKean Plumbing Heating & Supply Co regarding the instillation of the new water heater, Maintenance/Repair Work Order dated January 11, 2016 and the Residential Inspection Safety Checklist.[Within 30 days of receipt of the plan of correction, CEO or designated staff person will train staff persons responsible for monthly and quarterly water temperature checks on the procedures to address when water temperature at the bathtubs or showers exceed 120°F. Documentation of checks and trainings shall be kept. (AS 7/21/16) 05/25/2016 Implemented
6400.80(a)There was a 4 feet long and 6 inches wide crack in the sidewalk in the front of the home that poses a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. A new sidewalk was installed April 14, 2016 (see submitted pictures). This is also a part of the Quarterly Safety Checks done by the Safety Committee (see submitted Residential Inspection Safety Checklist). Maintenance will be informed of future problem areas. [Within 30 days of receipt of the plan of correction, CEO or designated staff person will develop and implement policies and procedures to ensure outside walkways are free from ice, snow, obstructions and other hazards. CEO or designated staff person will train staff persons responsible for ensuring that outside walkways are free from ice, snow, obstructions and other hazards; as well as, staff persons completing quarterly checks on the polices and procedures to ensure outside walkways are free from ice, snow, obstructions and other hazards. Documentation of checks and trainings shall be kept. (AS 7/21/16)] 04/14/2016 Implemented
Article X.1007Washington-Greene Residential Service, Inc. is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA)(35 P.S. 10225.101 - 1-225.5102) and its regulations (6 Pa. Code Ch.15). Direct Service Worker #1, hired on 5/12/15, who resides outside of Pennsylvania did not have a criminal history background check through the Department of Aging in accordance with OAPSA.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.A Criminal History Background Check was performed on this Direct Service Worker, however, the administrative staff person who completed the registration for the FBI Fingerprint on-line inadvertently check the wrong box. As soon as the inspector found the error, we contacted the employee and performed another Criminal History Background Check through the Department of Aging in accordance with OAPSA. The administrative staff was in-serviced on our FBI Applicant Fingerprinting Online Services Policy, outing step-by-step directions regarding criminal history background checks through the Department of Aging in accordance with OAPSA. We have previously submitted a copy of the in-service sheet. [DSW #1's background check from the Department of aging in accordance with OAPSA was completed January 27, 2016. Immediately, the CEO or administrative staff person will review all staff records to ensure required background checks are completed and will complete as necessary. Prior to hire, the CEO or administrative staff will review the prospective hire information to ensure the required background checks in accordance with OAPSA is being requested. At least quarterly, the CEO will review a 25% sample of new hire information including background checks once completed to ensure administrative staff is following aforementioned policy. (AS 7/21/16)] 01/08/2016 Implemented
SIN-00073436 Renewal 01/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)A handful of lint was pulled from the outside dryer vent which presented a fire hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. Dryer was cleaned on 1-13-15. Monthly checks will be done by maintenance department at all locations 01/25/2015 Implemented
SIN-00148614 Renewal 01/07/2019 Compliant - Finalized
SIN-00128211 Renewal 01/23/2018 Compliant - Finalized