Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00176559 Renewal 09/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)A Fire extinguisher was kept on the floor of the kitchen between two doors which creates a tripping hazard for individuals moving from room to room. A Fire extinguisher was kept on the floor in the hallway of the second-floor bedroom level which creates a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: Hope Enterprises will immediately relocate the fire extinguishers in the kitchen and upstairs hallway to areas that are not tripping hazards. 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: Hope Enterprises will inspect every licensed 6400 facility¿s floors, walls ceilings and other surfaces to ensure that they are free of hazards, particularly with respect to tripping hazards. Hope Enterprises will remove any hazards identified during inspection. Documentation will be maintained and available for on-site review. 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: Hope Enterprises will retrain all staff on the requirement that all facilities¿ floors, walls, ceiling and other surfaces are free of hazards with particular emphasis on tripping hazards. Hope Enterprises will update its policies to require staff to inspect facilities¿ floors, walls, ceiling and other surfaces for hazards at least once a month and to remove any identified hazards. Documentation will be maintained and available for on-site review. 4. STEPS HOPE WILL TAKE TO APPLY QUALITY ASSURANCE METHODS AND TO AUDIT IMPLEMENTATION OF STEP 3 TO VERIFY CONTINUED COMPLIANCE: Hope Enterprises Corporate Compliance Department will randomly audit 6400 licensed facilities at least once annually to ensure walls, ceilings and other surfaces are free of hazards. During the audit, Hope Enterprises will inspect all 6400 licensed facilities floors, walls, ceilings and other surfaces to ensure that they are free of hazards. DATE BY WHICH ALL PLAN OF CORRECTION ELEMENTS WILL BE COMPLETED: 11/27/2020 11/27/2020 Implemented
SIN-00113605 Renewal 06/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was only 1 very dim light in each room-living room and sitting room. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 6/9/17, Residential Director purchased three lamps. There are 3 lamps in the living room and 2 lamps in the sitting room. See attachment (5th Street #9). Residential Directors and Habilitation Managers reviewed Regulation 6400.66 and checked each house for adequate lighting by 6/29/17. See attachment (5th Street #4). Administrative Coordinator will train Habilitation Staff on Regulation 6400.66 by 7/21/17 (Strawbridge 5a). 07/21/2017 Implemented
6400.67(a)The upstair shower faucet was broken/stuck. Water came out bother the shower and the faucet at the same time with little water pressure. Floors, walls, ceilings and other surfaces shall be in good repair. On 6/22/17, the landlord repaired the upstairs shower faucet. See attachments (5th Street #8). Residential Directors and Habilitation Managers reviewed Regulation 6400.67(a) and checked each home to ensure shower faucets worked properly by 6/29/17. See attachment (5th Street #4). Administrative Coordinator will train Habilitation Staff on Regulation 6400.67(a) by 7/21/17 (attachment Strawbridge #5a). 07/21/2017 Implemented
6400.68(b)The water temperature was 122.3F. This exceeded the allowed 120F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Administrative Coordinator calibrated the thermometer and took a total of 9 readings with 3 separate thermometers for this home on 6/13/17. All readings were under the 120 degrees. Administrative Coordinator calibrated all thermometers in all the homes. Administrative Coordinator took 9 readings at each home and all readings were under the 120 degrees. See attachment (5th Street #6). Water temperature is checked twice daily and documented on the Daily Activity List. See attachment (5th Street #7). Administrative Coordinator will train all staff on ice bath calibration of thermometers by July 21, 2017, (attachment Strawbridge #5a). 07/21/2017 Implemented
6400.71The telephone did not contain the number for the fire, police and ambulance. it only listed 911. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. On 6/9/17, new labels with local emergency numbers for fire, police and ambulance were placed on all the telephones in the home. See attachment (5th Street #3). Residential Directors and Habilitation Managers reviewed Regulation 6400.71 and checked each house for compliance by 6/29/17. See attachment (5th Street #4). Residential Directors and Habilitation managers are ensuring compliance by utilizing the checklist for Residential homes at their monthly home visit. See attachment (5th Street #5). Administrative Coordinator will train Habilitation Staff on Regulation 6400.71 by 7/21/17 (attachment Strawbridge 5a). 07/21/2017 Implemented
6400.151(a)Staff person #1 did not have a 2016 physical in the record. The last physical on file was 11/3/14. The agency stated they overlooked this staff person. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff person #1 physical was completed on 6/7/17. See attachment (5th Street #1). Administrative Manager failed to place Staff person #1 into a tracking system as part of the hiring process. On 6/6/17 Administrative Manager reviewed staff physical records for timely completion. All staff physicals are current. See attachments (5th Street #2). The physical was added to the hiring checklist, (attachment 5th Street #2a). 06/19/2017 Implemented
6400.151(c)(2)Staff person #1 did not received a Mantoux in 2016. The last on on file was 6/5/14. The agency stated they over looked this staff person. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff person #1 received mantoux on 6/6/17. Mantoux was read with negative results on 6/8/17. See attachment (5th Street #1). Administrative Manager failed to place Staff person #1 into a tracking system as part of the hiring process. On 6/6/17 Administrative Manager reviewed staff mantoux records for timely completion. All staff mantoux records are current. See attachments (5th Street #2). The mantoux record was added to the hiring checklist, (attachment 5th Street #2a). 06/19/2017 Implemented
SIN-00094781 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written evaucation plan did not include individual responsibilities in the event of an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Administrative Coordinator revised the written evacuation plan to include individual responsibilities in the event of an emergency on 6/3/16, see attachment, (5th Street. #1). The Administrative Coordinator revised Emergency Evacuation Plans for 15 homes on 6/3/16, see attachment (6th Street #2). The Director/Manager will review with individuals their responsibilities on the revised evacuation plan by 7/30/16, (attachment 5th St. #3). 07/30/2016 Implemented
6400.181(e)(13)(ii)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in motor and communication skills. This section contained the same information as the previous assessment. 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. On 6/6/16, the Director revised Individual #1's assessment to include a change in her motor and communication skills, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(iii)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in residential living. This section contained the same information as the previous assessment. 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. On 6/6/16, the Director revised Individual #1's assessment to include a change in residential living, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(iv)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in personal adjustment. This section contained the same information as the previous assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in personal adjustment, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(v)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in socialization. This section contained the same information as the previous assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in socialization, attachment (5th St, #2). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(vi)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in recreation. This section contained the same information as the previous assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in recreation, attachment (5th St, #2). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(viii)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in managing personal property. This section contained the same information as the previous assessment. 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. On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in managing personal property, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.181(e)(13)(ix)Individual #1's 8/14/15 assessment did not include progress or regression over the past year in community integration. This section contained the same information as the previous assessment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in community integration, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). 06/06/2016 Implemented
6400.185(b)Individual #1's Individual Support Plan (ISP) indicates progress is being made when Individual #1 controls his/her anger with less than 20 displayed instances to decrease monthly once goal is met. This information is not being tracked or reported on Individual #1's ISP reviews or monthly documemation. The ISP shall be implemented as written.On 5/13/16 Program Director reviewed with Habilitation Manager the documentation requirements of Individual #1's relationship outcome, attachment (5th St, #7). Habilitation Manager reviewed with staff the documentation requirements of Individual #1's relationship outcome, attachment (5th St. #8). 05/13/2016 Implemented
6400.186(c)(2)Individual #1's 3/21/16, 12/17/15, 9/18/15, and 6/8/15 Individual Support Plan (ISP) reviews did not provide an update on the social, emotional, environmental needs plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. On 6/2/16 Assistant Vice President trained Program Directors on Regulation 186(c)(2), attachment (3rd Ave #9). Program Director will include an update on Individual #1's social, emotional, environmental needs plan on the next ISP review due 6/17/16, attachment (5th St., # 6). 06/30/2016 Implemented
6400.213(11)Individual #1's Individual Support Plan (ISP) indicated he/she is able to have 8 hours of alone time at home and 7 hours of alone time in the community. The 8/14/15 assessment indicated he/she is able to have 7 hours of alone time. The supervision plan indicated he/she is able to have 7 hours of alone time in the home or in the community. The 3/17/16 ISP review indicated he/she is able to have 7 hours of alone time. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. On 6/6/16 Program Director revised Individual #1's assessment to be consistent with the ISP, attachment (5th St. #2). On 6/6/16 Program Director revised Individual #1's supervision plan to be consistent with ISP and assessment, attachment (5th St. #5). On 6/2/16 Assistant Vice President trained Program Directors on Regulation 213(11), attachment (3rd Ave #9). 06/06/2016 Implemented
SIN-00210308 Renewal 09/14/2022 Compliant - Finalized
SIN-00157500 Renewal 07/30/2019 Compliant - Finalized
SIN-00111388 Renewal 06/26/2017 Compliant - Finalized