Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227058 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. The agency provided water testing documents dated 11/17/22, 2/16/23 and 6/6/23. This exceeds the time requirement.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Provider's water testing laboratory went out of business with little notice. The provider established accounts with a new water testing laboratory and testing was done as quickly as possible but exceeded the quarterly requirement, resulting in a late water test. 08/23/2023 Implemented
6400.141(a)The individuals should have a physical exam prior to moving in and then annually thereafter. Individual #1 had his physical exam prior to his admission on 12/3/21. The next physical exam was not completed until 1/5/23. This exceeds the time frame.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Provider added a note to individual #1's file to explain why the physical exam was late. Provider reviewed upcoming annual physical due dates to ensure that appointments were scheduled within annual time frame. 08/25/2023 Implemented
6400.142(a)Individual #1 has not had a dental exam since living at the program. Individual #1 had an appointment on 10/25/22 at Tobyhanna Dental which the Dentist did not complete an exam and was referring Individual #1 to see a Dentist who specialized with special needs. The agency contacted several dental offices on 10/31/22 all of which were not taking new patients, or they were not accepting Individual #1's insurance. The next attempt at calling for a dental was on 1/16/23 which was unsuccessful. The next attempt to schedule Individual #1 was on 8/3/23 which reflects he has an appointment on 8/28/23 at 12:30pm at Tobyhanna Dental. This was the dental provider who referred Individual #1 out last October.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 has a dental appointment scheduled on 8/28/23 and 9/26/23. These appointments were made with 2 different dental providers in case the first appointment was unsuccessful. Program supervisors were retrained on what resources to use to find providers covered by the individual's insurance. 08/25/2023 Implemented
SIN-00191812 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Evacuation time for the fire drill conducted on 7/14/21 exceeded requirement. Evacuation time was documented as three minutes and forty-eight seconds (3:48.) A repeat drill was conducted on 7/15/21 with a successful evacuation at one minute and twenty-eight seconds (1:28.) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. After fire drills house managers will have a discussion with all participants on the importance of evacuating quickly, safely and meeting at the designated areas. Discussions will also be had at house meetings on the importance of fire safety. 09/08/2021 Implemented
SIN-00178331 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no documentation to show that a fire drill was held during the month of July 2020. An unannounced fire drill shall be held at least once a month. Monthly Fire Drills are now being tracked by the Administrative Assistant to the ID Department. All Fire Drill are due to the Program Directors within three days of the fire drill and approved by them and then passed on to the AA who enters the drill into the Excel spreadsheet. If one is not received by the PD or the AA within that time frame than the program manager will be notified to conduct the monthly fire drill. See copy of spreadsheet 10/30/2020 Implemented
6400.142(c)Individual #1 had a dental check-up in February 2020. A follow up appointment was scheduled for 8/21/20 but there was no documentation or record to show that the follow up appointment occurred.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. A dental appointment is scheduled for 12/21/2020. Our Program managers now have Agency provided cell phones with have outlook in them so the Manager will input the next appointment into the Agency cell phone prior to leaving the medical appointment. The Agency cell phone will then upload that appointment into the program computer. 12/02/2020 Implemented
SIN-00134384 Renewal 05/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Liquid hand soap was found not in the original containers on the sink vanity tops in both bathrooms in the home. The hand soap was labeled as a poisonous substance.Poisonous materials shall be stored in their original, labeled containers. The program staff who put the soap in a different container was re-trained the day of licensing. See attached form. 05/02/2018 Implemented