Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230573 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1 uses a shower chair. During the 10/5/23 inspection, the mesh on their shower chair was very dirty, containing partials and chunks of matter stuck within the mesh that were black, brown, white, and some red in color.Clean and sanitary conditions shall be maintained in the home. 10/16/23 Program specialist received an invoice from Duralife USA for Individual #1 to purchase new mesh for the shower chair Individual #1 owns. (Attachment #2) 10/13/23 Program specialists and working managers were trained on their responsibilities including: clean and sanitary conditions shall be maintained in the home. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify clean and sanitary conditions will be maintained in the home. (Attachment #1) 10/13/2023 The SFI Safety Inspection Checklist was updated to include the following inspection: Clean/sanitary conditions-including equipment such as shower chairs. (Attachment #3) 10/17/2023 Implemented
SIN-00213394 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 3/9/22 identified the following violations: 67a. There was no written summary of corrections.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. 10/26/2022- All program specialists and working managers were trained on their responsibility that self-assessment results and a written summary of corrections made shall be complete and kept by the agency for at least one year. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists and working managers will continue to complete self-assessments per the regulations and regulatory compliance guide to ensure all regulations are answered and a written summary of corrections is completed if a regulation is in violation. 10/25/2022- The Self-Assessment front page was updated to include the program specialist and program director signatures to indicate the self-assessment was completed correctly. The signatures verify all regulations were reviewed and documented. They also verify a written summary of corrections were completed for all regulatory violations (if applicable). 10/26/2022 Implemented
SIN-00198058 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(h)Ketoconazole 2% Cream was discontinued 06/29/21; however, the cream was kept with the current medications at the time of the 12/14/21 inspection.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.1/3/22 All program specialists and the LPN were trained on their responsibility that prescription meds that are discontinued or expired shall be destroyed in a safe manner according to applicable Federal and State statutes and regulations. 1/3/22 A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that all prescription meds that are discontinued or expired shall be destroyed in a safe manner according to applicable Federal and State statutes and regulations. All program specialists have reviewed and verified that all prescription meds that are discontinued or expired have been destroyed in a safe manner. 12/14/21 Disposal of Drugs form was completed for Ketoconazole 2% cream and Pharmacy was contacted to pick up medications to be disposed. Ketoconazole 2% cream was picked up by Pharmacy for disposal (Attachment #2). 01/04/2022 Implemented
SIN-00141414 Renewal 10/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The refrigerator door and the back/main entrance to the home door was extremely dented to the point of causing ripples in the doors.Floors, walls, ceilings and other surfaces shall be in good repair. November 8, 2018- All Program Specialists were trained on their responsibilities that all floors, walls, ceilings, and other surfaces shall be in good repair. A training record was signed indicating their attendance and understanding. A maintenance request was completed to put plexiglass on the refrigerator door and back/main entrance door. November 15, 2018- Plexiglass installed and both projects are completed. A monthly review will be completed by a member of the safety committee evaluating the homes floors, walls, ceilings, and other surfaces to ensure they are in good repair. This process is completed at each home on a monthly basis. All agency homes have been reviewed and evaluated to ensure that floors, walls, ceilings, and other surfaces are currently in good repair. The ID Director will review all agency homes to ensure compliance on a quarterly basis. 11/15/2018 Implemented
6400.103The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation. November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. 11/12/2018 Implemented
6400.112(i)A smoke detector wasn't sent off for every fire drill. Occasionally the smoke detector was set off in 309 Fry Drive residential home that is attached to 311 Fry Drive (a separate licensed home) and the smoke detectors are inner connected. A fire alarm or smoke detector shall be set off during each fire drill.November 8, 2018- All Program Specialists were trained on their responsibilities that a fire alarm or smoke detector shall be set off during each fire drill. A training record was signed indicating their attendance and understanding. The agency fire drill record has been revised with instructions stating that ¿Interconnected detectors at 309/311 Fry Drive and 1259 A/B Old Boalsburg Road must have a smoke detector set off at each home during each fire drill.¿ November 13, 2018- A fire drill was conducted at 309 and 311 Fry Drive with a smoke detector being set off at each location during the fire drill. All fire drill records were reviewed to verify that a fire alarm or smoke detector was set off during each fire drill. All agency fire drill records have been reviewed by the ID Director to verify that a fire alarm or smoke detector is set off during each fire drill at each home. The ID Director will review all fire drill records at each home to ensure compliance on a quarterly basis. 11/13/2018 Implemented
SIN-00100038 Renewal 08/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1's financial log entry on 8/14/15 indicated that $4 was withdrawn for a pizza lunch at day program. The receipt for 8/14/15 was only for $3. On 1/25/16 there was a withdrawl of $13.01 for Mcdonalds. The receipt indicated that only $6.99 was spent at McDonalds on 1/25/16. On 6/28/16 there was a receipt for McDonalds for $2.54. The financial log indicated that $2.46 was spent at McDonalds on 6/28/16. Individual #1's financial log has not been correct since August of 2015 until present. (2) Disbursements made to or for the individual. All Program Specialists were trained on their responsibilities concerning regulation 6400.22(d)(2) the home shall keep an up-to-date financial and property record for each individual that includes the following: Disbursements made to or for the individual (See attachment #1). Individual # 1s financial ledger was corrected to reimburse him/her for staff transaction documentation errors that occurred on 8/14/15, 1/25/16, and 6/28/16 (see attachment #7). The Program Specialist revised the Financial Ledger document to include a monthly review by the Program Specialist with signature required to ensure all records and transactions are complete and documented correctly (see attachment #7). 10/10/2016 Implemented
6400.46(f)Staff #1 received fire safety training on 10/2/14 and not again until 10/7/15.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The training coordinator has been trained in the responsibilities concerning regulation 6400.46(f). Program Specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. (See attached #1) Staff will be notified of upcoming required trainings via posted flyers at least 30 days prior to the scheduled training to ensure ample notification and planning. Currently fire safety training is offered upon hire and annually thereafter-an additional fire safety training will be added to the training curriculum year and tracked by the training department to ensure all are trained in a timely manner. Staff #1 has completed the annual fire safety training on 10/17/15 and 9/1/16. Therefore, currently staff # 1 is in compliance. (See attachment #7). 10/10/2016 Implemented
6400.76(e)The home did not have a dining room table or a place with seating for all individuals at the same time. In homes serving eight or fewer individuals, there shall be dining tables with seating for all individuals at the same time.All Program Specialists were trained on their responsibilities concerning regulation 6400.76(e) in home serving eight or fewer individuals there shall be a dining table with seating for all individuals at the same time (See attachment #1). The Program Specialist updated the Individual Support Plans for the individuals living in the home to include their choice to not have a dining room table in their home. This is due to both individuals using motorized wheelchairs with molded seating and trays that attach to their arm rests. The trays suffice as a surface they can use to eat their meals (see attachment #6). All other Strawberry Fields residential homes contain dining room tables and chairs for all individuals. The Program Specialist will be responsible to ensure that there is a dining table at all programs unless individuals choose otherwise based on their choices, needs and equipment. 10/10/2016 Implemented
6400.142(g)On 3/17/16 Individual #1's dentist recommended that he/she/staff use gauze to wipe the plaque off his/her teeth if Individual #1 does not tolerate a toothbrush. This was not updated on the dental hygiene plan. A dental hygiene plan shall be rewritten at least annually. All Program Specialists were trained on their responsibilities concerning regulation 6400.142(g) a dental hygiene plan shall be rewritten at least annually (See attachment #1). The Program Specialist revised individual #1s dental hygiene plan to reflect current recommendations by the dentist which are to use gauze to wipe the plaque off her teeth if individual #1 does not tolerate a toothbrush (see attachment # 4). All Program Specialists will review the dental hygiene plan quarterly to ensure current recommendations are documented in the Individual Support Plan (see attachment # 5). 10/10/2016 Implemented
6400.164(b)Individual #1's Miralax Powder was not signed after administration at 8am on 10/31/15. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. All Program Specialists were trained on their responsibilities concerning regulation 6400.164(b). The information specified in subsection (a) shall be logged immediately after each individuals does of medication is administered (See attachment #1). The Program Specialist revised the Medication Administration Sign-off Sheet to include a monthly review with signature required by the Program Specialist or Lead Direct Support Professional to ensure that all med logs are reviewed each month and that all records are complete and/or documented correctly on the Medication Log Explanation Sheet (if needed) (see attachment #2). In addition the medication administration log for Individual # 1 was reviewed and all records were complete and/or documented correctly for the month of September 2016 (see attachment #2) A review of all individual records was completed to ensure all records were complete and/or documented correctly for the month of September 2016 (see attachment #3) 10/10/2016 Implemented
SIN-00065879 Renewal 06/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was used as the exit route for every fire drill in the past year. The home has 2 exits.Alternate exit routes shall be used during fire drills. Sasha Juba, Program Specialist, was trained in her responsibilities (see attachment #1). Strawberry Fields will construct a new ramp, widen the back door and make any/all changes to interior of home to allow alternate exit routes to be used during fire drills. A meeting with M & E Construction is scheduled for Thursday, Aug 7 at 2pm at 311 fry drive. 10/30/2014 Implemented
SIN-00072896 Renewal 06/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The front door was used as the exit route for every fire drill in the past year. The home has 2 exits.Alternate exit routes shall be used during fire drills. See POC by provider in original inspection 12/30/2014 Implemented
SIN-00180495 Renewal 12/15/2020 Compliant - Finalized
SIN-00048014 Renewal 05/30/2013 Compliant - Finalized