Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00199903 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(1)Chief Executive Officer #1's training on community integration, individual choice, and supporting individuals to develop and maintain relationships consisted of her reading the agency's policy and procedures on 8/26/2020. Program Specialist #2's training on community integration, individual choice, and supporting individuals to develop and maintain relationships consisted of her reading the agency's policy on 8/17/2020. Direct Service Worker #3's training on community integration, individual choice, and supporting individuals to develop and maintain relationships consisted of her reading the agency's policy on 6/14/2021. Direct Service Worker #4's training on community integration, individual choice and supporting individuals to develop and maintain relationships consisted of his reading the agency's policy on 8/31/2020.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.I have created a training module in Elsevier that covers lessons in Person Centered Planning, Prevention, recognition and reporting of abuse and Resident rights. I have assigned these lessons to all staff including myself (CEO) and RPS. Each year, I will find a new source for these trainings. 02/15/2022 Implemented
6400.52(c)(2)Chief Executive Officer #1's training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse consisted of her reading the agency's policy and procedures on 12/21/2020. Program Specialist #2's training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse consisted of her reading the agency's policy and procedures on 12/01/2020. Direct Service Worker #3's training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse consisted of her reading the agency's policy and procedures on 10/06/2020. Direct Service Worker #4's training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse consisted of him reading the agency's policy and procedures on 12/08/2020.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.I have created a training module in Elsevier that covers lessons in Person Centered Planning, Prevention, recognition and reporting of abuse and Resident rights. I have assigned these lessons to all staff including myself (CEO) and RPS. I have also Assigned to ALL STAFF INCLUDING myself and RPS, a Webcast from PA DoAging on the OAPSA overview and a Power POint on Mandated Reporters from the Dept of Human services. Staff are required to watch/read both, write a summary, date and sign and turn in to the office by April 1. Each year, I will find a new source for these trainings. 02/15/2022 Implemented
6400.52(c)(3)Chief Executive Officer #1's training on individual rights consisted of her reading the agency's policy and procedures on 8/26/2020. Program Specialist #2's training on individual rights consisted of her reading the agency's policy and procedures on 8/17/2020. Direct Service Worker #3's training on individual rights consisted of her reading the agency's policy and procedures on 6/14/2021. Direct Service Worker #4's training on individual rights consisted of him reading the agency's policy and procedures on 8/31/2020.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.I have created a training module in Elsevier that covers lessons in Person Centered Planning, Prevention, recognition and reporting of abuse and Resident rights. I have assigned these lessons to all staff including myself (CEO) and RPS. Each year, I will find a new source for these trainings. 02/15/2022 Implemented
SIN-00127866 Renewal 01/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1's medication reviews completed 5/16/17 did not include reason for prescribing the medication, need to continue the medication and the necessary dosage. Individual #1's medication review completed 6/27/17 did not include reason for prescribing the medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All staff have been instructed that they must make sure the Med review form is completed in its entirety for each med review visit. Med review forms will be turned in to the Program Specialist for review after each med review appointments. If the form is not completed correctly, contact will be made with the Doctor's office for correction. The Program Specialist will report on Med Review forms at the monthly management meeting. [Immediately, the CEO shall train all staff person responsible for assisting individuals' in psychiatric medication reviews and all staff responsible for reviewing documentation by a licensed physician of the requirements as per 6400.163(c) and the aforementioned procedures to obtain missing information. Documentation of staff trainings shall be kept. Documentation of aforementioned audits and requests for missing information shall be kept. (AS 1/30/18)] 01/24/2018 Implemented
SIN-00070843 Renewal 10/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff Person #1 who has direct contact with individuals, hired 12/20/11, does not have a Pennsylvania criminal history record check completed.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. This staff had a recent federal clearance that I mistakenly believed met the regulations. Since I (the CEO) supervisor all hiring, I now know that I will not accept any criminal history clearances unless they are through the patch system and are within the required time frame. [PA Patch criminal history check obtained for staff person #1 and does not contain any prohibitive offenses. The CEO will audit all current staff records to ensure they have a criminal background check completed through the pa patch system and meet all requirements per oapsa. (CHG 12/3/14)] 11/17/2014 Implemented
6400.151(c)(2)Staff person #1 had a Tuberculin skin test completed on 11/5/11 and 12/19/13. 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. This staff was hired in Dec. of 2011. He had a TB test in November of 2011 and I accepted it even though he had to have a new physical at that time. THus his tb test was 1 month earlier than his physical. In tracking his updated (2yr) physical and TB test, the clerk only noted his physical date and therefore his TB test was one month late. From this point on, tracking for TB test and physical will be noted separately by the office clerk who tracks this information. As for this staff, his physical and TB test were done on the same date in 2014 and so his compliance tracking will not be a problem. 11/17/2014 Implemented
SIN-00042334 Renewal 10/01/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)The medication administration records for individual #1, dated 1/9/12, 1/10/12, 1/11/12 does not indicate the name of the person that administrated the medications of Celexa, 40mg tablets given at 8:00 A.M., Zonegran, 100mg caplets given at 8 A.M., Dilantin, 100mg caplets given at 8 A.M., and Loprox, .77% Cream applied at 8 A.M. Partially Implemented - Adequate Progress - MZ - 2/11/2013.(a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Staff signatures were entered into the log on 10/2/12. Staff was retrained by the CEO on 10/2/12. (3 MARs that have been completed correctly by this staff have been faxed to licensing.) There is a system in place to prevent and catch med errors that is implemented by the program Supervisors and the Administrative Officer. As of our October Management mEETING we have added an additional step that will be implemented bhy the Program Supervisors. 01/30/2013 Implemented
SIN-00217327 Renewal 01/10/2023 Compliant - Finalized
SIN-00184470 Renewal 03/09/2021 Compliant - Finalized
SIN-00146867 Renewal 12/13/2018 Compliant - Finalized
SIN-00106112 Renewal 01/05/2017 Compliant - Finalized