Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228867 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1's financial tracking for August 2023 shows an ending balance of $92.37 spent in August. However, September 2023's starting balance was $81.50. The balance is off by $7.37 and there is no explanation. Additionally, a purchase made on 8/31/23 is listed on the September 2023 financial log instead of the August log.(2) Disbursements made to or for the individual. The individual was reimbursed $7.37 after the completion of an investigation. The reimbursement was made on 10-13-2023. All staff were retrained on regulation 22c by Director of residential Services Leo Marcantonis on 10-6-2023. The residential management will be further retrained on this regulation in an in-person training on October 25th. 11/22/2023 Implemented
6400.141(c)(9)Individual #1's physical exam dated 3/22/23 left the prostate examination section blank. The there is a document located in the Individual's record that state that prostate exams are waived due to having PSA levels checked yearly, however this section cannot be left blank on the physical.The physical examination shall include: A prostate examination for men 40 years of age or older. Letter obtained from PCP on 9-28-23 stating that individual #1 is followed by urology and that per the physical Exam on 3-22-23, a prostate exam is deferred due to having his PSA levels completed yearly. His most recent PSA was completed on 6-16-23. All management were retrained in this regulation by Director of Residential Services in 10-10-23. The residential management will be further retrained on this regulation in an in-person training on October 25th. 10/13/2023 Implemented
6400.183(a)(3)Individual #1's ISP meeting on May 23, 2023 does not include a direct care staff persons.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.- Director of Residential Services provided verbal and written education/retraining to Program Specialists on 10-9-23 regarding regulation 183a3 an individual's plan will be developed by the individual's interdisciplinary team which includes the direct care staff persons of the individual. - The Program Specialist of Individual #1 with an ISP meeting of May 23, 2023 provided an opportunity for direct care staff persons of the individual to submit recommended changes and updates for Individual #1's ISP dated May 23, 2023 on 10-23-23. No feedback was received as of yet from the DSPs. When feedback is provided, we will forward the updates to the SC. 10/30/2023 Implemented
SIN-00210875 Renewal 09/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 2/28/22 indicated a violation for 141a. A written summary of correction was not noted for this violation.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. The management team was retrained by Director of Residential Services on 9-27-22 in regard to regulation 6400.15. The management team was retrained by Residential Services Director on 9-27-22 in regard to Regulation 141a. 10/03/2022 Implemented
SIN-00210979 Unannounced Monitoring 07/11/2022 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were left unlocked in the main floor bathroom during the inspection. (Lysol spray, Febreeze, Chlorox wipes, Steramine and others)Poisonous materials shall be kept locked or made inaccessible to individuals. All staff were retrained on this regulation on 9-19-22. The items found to be unlocked were immediately locked up. 09/19/2022 Accepted
6400.64(f)Outside trash receptable at the side of the house was overflowing so that the lid would not close.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The team was retrained on 9-19-22 in regards to this regulation. The team was spoken to and they stated that the trash does not usually overflow and they were retrained in this regulation. The home will also be purchasing a larger trashcan. 09/19/2022 Accepted
6400.144REPEAT FROM 3/22/22. Calmal 4 suppository was not given on at bedtime on July 3rd and 4th. When questioned about this, staff stated it was because they did not have the medication.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Staff were retrained immediately on this regulation. The entire residential department was retrained on 9-19-22. 09/19/2022 Accepted
6400.214(b)REPEAT FROM 3/22/22. Most current record information was not available in the home The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The current record was missing the most up to date ISP. This was printed and filed on 7-11-22. The residential management team was retrained on this regulation by Leo Marcantonis on 9-16-22. 09/16/2022 Accepted
6400.50(a)REPEAT FROM 3/22/22. CPAP and Diabetes trainings did not list the duration of the trainingsRecords of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The original training log can not be located in order to go back to add the duration of the training. All trainers were retrained on 9-19-22 to ensure that all internal trainings have a training log and that the log is handed in to HR in order to be documented in our Relias Training system. 09/19/2022 Accepted
6400.163(d)Hydrocortisone Cream 1% was lying on a desk in the basement during the inspection.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.All staff were retrained on this regulation on 9-19-22. The item found to be unlocked was immediately locked up. 09/20/2022 Accepted
6400.166(a)(2)REPEAT FROM 3/22/22. Name of prescriber not listed on any of the MARs.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the Name of the Prescriber is listed on the MAR. 09/19/2022 Accepted
6400.166(a)(5)REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing strength of medication,A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the strength of the medication is listed. 09/19/2022 Accepted
6400.166(a)(6)REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing dosage formA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the dosage form is listed accurately on the MAR. 09/19/2022 Accepted
6400.166(a)(7)REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing dose of medicationA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the dosage is listed accurately on the MAR. 09/19/2022 Accepted
6400.166(a)(9)REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing frequency of administration,A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the frequency is listed accurately on the MAR. 09/19/2022 Accepted
6400.166(a)(11)REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing diagnosisA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the diagnosis is listed accurately on the MAR. 09/19/2022 Accepted
SIN-00192195 Renewal 09/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed from 12/1/21 to 2/28/21 identified 141c7 as a violation. No written summary of corrections was completed for this violation.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. Associate Directors will ensure that there is a written plan of correction for each violation cited on the self-assessments. They have referenced Appendix E in the RCG named Best Practices in Documenting Regulatory Violations which can be found starting on page 142 through page 154. It is mandatory that all Associate Directors reviewed this by Wednesday, September 15th, 2021. 09/15/2021 Implemented
6400.106Documentation was provided that the furnace was cleaned on 1/2/20 and not again until 1/20/21; outside of the annual time frame.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Associate Director was retrained on the regulation regarding scheduling furnace cleanings within the annual time frame on 9/10/21. 09/10/2021 Implemented
6400.141(c)(8)Individual #1's physical examination form date 3/25/21, indicated that a mammogram was ordered for individual #1, but there is no verification that the mammogram was completed.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Individual #1 moved in without a mammogram on record. Individual #1 had the mammogram on 4-6-21 which was less than a month after moving into the home. Documentation of the mammogram has been obtained. 09/17/2021 Implemented
6400.142(c)PAI states that Individual #1 had a dental examination completed on 4/27/21. PAI states they do not have a written record of this exam.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. Individual #1 had their dental appointment two days prior to moving in. However, there was no form on file that stated what was done at the appointment and when the appointment was completed. Documentation of the dental exam and cleaning which occurred on 4-27-21 was obtained. Discussion for Plan of Correction An email was sent to all Residential Program Supervisors, Associate Directors and Program Specialist to re-iterate the importance of compliance with ensuring we have everything needed prior to moving a new individual in as well as for each person served. All Associate Directors will sign this plan of correction to ensure we follow suit, prior to moving in a new individual and if not possible to have that information on hand, we will call to obtain these appointments immediately upon entry to the residential facility. 09/17/2021 Implemented
6400.144(Repeat Violation from Inspection completed 9/22/20) Individual's #1 physical examination form date 3/25/21, indicates that individual #1 is prescribed Lorazepam (as needed) prior to doctor's appointments. This PRN medication has not been administered for any appointments conducted since individual #1's been receiving services from PAI. Individual #1 was prescribed Acetonel 35mg for low bone density on 6/29/21, this medication was not administered to individual #1 until 8/18/21.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. It was discussed with staff, the importance of making sure when a medication is prescribed it will be started immediately by following up with the pharmacy to ensure they have the script and that they can fill it or taking it to another pharmacy to obtain the medication, if it cannot be filled by our regular pharmacy. It is our responsibility to ensure medications prescribed are given and started immediately upon order. 09/13/2021 Implemented
6400.166(a)(2)Individual #1 medication administration records don't include the name of the prescribers for the medications administered.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The prescribing physician was added immediately, upon discover of the violation, to the Medication Administration Record. 09/15/2021 Implemented
6400.186Individual #1's ISP dated 8/27/21 states that due to Individual #1's pre-diabetic diagnosis, exercise is recommended. PAI is not able to provide evidence that this recommendation is being offered or encouraged as ordered.The home shall implement the individual plan, including revisions.Clarifying documentation was received from the PCP regarding the expectation for exercise and a documentation record was implemented to record if Individual #1 did exercise. 09/13/2021 Implemented
SIN-00154502 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The carpeted basement steps contained black and brown marks over the entire foot traffic area in the center of the steps.Floors, walls, ceilings and other surfaces shall be in good repair. I, Sara Quay, requested an estimate from Certified Carpet on 6/7/19. Paul Flinchbaugh from Certified Carpet came to Darby on 6/14/19 and examined the carpet on the stairs that go down into the basement. An estimate was then sent to Excentia. An appointment was then made for the carpet to be replaced, which is scheduled for 7/11/19. 07/11/2019 Implemented
6400.72(a)The back porch screen door contains an approximately 3-4 inch rip in the bottom of the screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. Aliyah Anderson, Program Supervisor for Darby, submitted a work order for the hole in the screen to be repaired on June 19th. Construction due to remodeling of the room where the screen door was located was scheduled to begin on June 24th and maintenance was not able to repair it prior to that. As part of the remodeling of the room to prepare it for a gentleman whose needs increased recently, this door was removed as part of the changes and was replaced with a French door on June 24th. 06/24/2019 Implemented
SIN-00105072 Renewal 02/07/2017 Compliant - Finalized
SIN-00064668 Renewal 04/08/2014 Compliant - Finalized