Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233051 Renewal 10/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1 had an annual assessment completed on 04/01/22, and then again on 04/21/23. This exceeds the annual requirement, Individual #2 had an annual assessment completed on 04/01/22, and then again on 04/25/23. This exceeds the annual requirement. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The annual assessment will be completed 365 days after the previous assessment as to be incompliance with regulation 181a. This agency will comply with the following : Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. 10/27/2023 Implemented
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. Individual #1 does not have record of 3-month psychiatric medication reviews completed in the last year.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.A 3 month review will be completed for all/any medications prescribed to treat a psychiatric illness. A licensed physician will review at least every 3 months including documentation for reason prescribed, the need to continue and the necessary dosage. And will comply with the following regulation listed below. If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 10/23/2023 Implemented
SIN-00214122 Renewal 11/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)The most recent physical examination for Individual #2 was completed 10/19/21.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Physical exam appointments with our provider can be made 1 year prior to needed date. Staff will make physical appointment upon leaving doctor's office. If unable to make appointment at that time due to doctor's office scheduling rules. Staff will ask when they able to call and make that appointment and staff will log information on to calendar of individuals appointments as to when they are able to call. Staff will keep a log in with calendar as to every attempt they make to call the provider and schedule the physical exam. 11/15/2022 Implemented
6400.141(c)(9)The most recent prostate examination for Individual #2, date of birth 4/10/39, was completed 10/19/21.The physical examination shall include: A prostate examination for men 40 years of age or older. Physical exam/prostate exam appointments with our provider can be made 1 year prior to needed date. Staff will make physical appointment upon leaving doctor's office. If unable to make appointment at that time due to doctor's office scheduling rules. Staff will ask when they able to call and make that appointment and staff will log information on to calendar of individuals appointments as to when they are able to call. Staff will keep a log in with calendar as to every attempt they make to call the provider and schedule the physical exam/prostate exam. 11/15/2022 Implemented
6400.142(a)Individual #1, date of birth 11/10/63, had dental examinations 7/6/21 and then again 8/3/22.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. Dental appointments with our provider can be made 3 months prior to needed date. Staff will call dental office 3 months prior to yearly dental date and schedule dental appointment. (This year as well as the last 2 years our dentist office has been difficult in making appointments as the have been back logged with trying to catch up with all the appointments that have been canceled.) 11/15/2022 Implemented
6400.51(b)(1)Chief Executive Officer #1, date of hire 1/1/22, received training in the application of: Person-centered practices, Community integration, Individual choice, and supporting individuals to develop and maintain relationships 4/1/22The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Director will set up training for Chief Executive Officer to be completed within 30 days of hire. 11/15/2022 Implemented
6400.51(b)(2)Chief Executive Officer #1, date of hire 1/1/22, received training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse 2/11/22.The orientation 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.Program Director will set up training for Chief Executive Officer to be completed within 30 days of hire. 11/15/2022 Implemented
6400.51(b)(3)Chief Executive Officer #1, date of hire 1/1/22, received training Individual Rights 2/7/22.The orientation must encompass the following areas: Individual rights.Program Director will set up training for Chief Executive Officer to be completed within 30 days of hire. 11/15/2022 Implemented
6400.51(b)(4)Chief Executive Officer #1 (Jennifer Malone), date of hire 1/1/22, received training in recognizing and reporting incidents 3/1/22.The orientation must encompass the following areas: recognizing and reporting incidents.Program Director will set up training for Chief Executive Officer to be completed within 30 days of hire. 11/15/2022 Implemented
6400.52(a)(1)Direct Support Worker #2 had 7.75 training hours for training year 7/1/21-6/30/22.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Staff was given a written warning 7/11/2022 stating that during the next training cycle 2022-2023, she is required to complete 3 hours of training each month from July 2002 thru the end of February 2023. The failure to complete said trainings would result in her termination of her position. As a result of her not completing her training, she did not receive her cost of living raise and would receive this increase if training was completed as stated. 11/15/2022 Implemented
SIN-00180207 Renewal 12/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 and Individual #2 were informed and explained Individual Rights on 2/01/2020. The Individual Rights document did not include the following rights: 6400.32d, to be treated with dignity and respect; 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j, to voice concerns; 6400.32k, to participation in the development and implementation of the individual plan; and 6400.32r through 6400.32s; relating to locking doors in bedrooms and in the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual rights form was updated and all individuals in this home signed new forms on 12/22/2020. The individual rights form will be read to and signed annually thereafter by each individual in this home. 12/22/2020 Implemented
SIN-00120363 Renewal 08/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1 had an assessment completed 5-1-17; the previous assessment was completed on 4-1-16. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The compliance officer will do quarterly case record reviews on individual records. The checklist was updated to include this years assessment and last years assessment indicating that they are to be no more than 1 year apart. The compliance officer was trained on 9/18/17 on the assessment dates and annual requirements. The next audit is scheduled for 9/29/17. [Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of all individuals' assessment. (AS 9/20/17)] 09/29/2017 Implemented
6400.213(10)(iv)The record for Individual #1 did not include documentation of the notices that the plan team members may decline the ISP reviews.Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. Notices were sent to team members to sign 9/7/2017. Declination was signed and returned on 9/13/17. All individual records had notices sent out to team members on 9/7/17 also. Quarterly the Compliance Officer will be doing case record reviews on individual records. There is a checklist in which the declination was added to be checked. Also these declinations will be scanned into the computer into individual files for future reference if forms become missing in their house file. The Compliance Officer was trained in the checklist audit and will be instructed as to the declination added to checklist on 9/18/17. 09/18/2017 Implemented
SIN-00102504 Renewal 10/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)The ISP reviews for Individual #1, dated 1/1/16, 3/31/16, 6/30/16 and 9/30/16 were completed by the house supervisor and reviewed and signed by the Program Specialist. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist will complete ISP review of services and expected outcomes in the ISP specific to the residential home licensed under 6400 regulations with the individual every 3 months beginning with next review which will be due January 2017.[Immediately, the Executive Director shall review the responsibilities of the program specialist as per 6400.44(b)(1)-(19) with the program specialist and sign and date. At least quarterly for 1 year, the executive director will review all completed ISP reviews to ensure completion by the program specialist. Documentation of reviews shall be kept. (AS 11/10/16)] 11/10/2016 Implemented
SIN-00079674 Renewal 09/01/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)A hole approximately 3 inches diameter, the shape of a doorknob was in the wall next to the cleaning supply closet in the kitchen.Floors, walls, ceilings and other surfaces shall be in good repair. Hole in wall at this residence was fixed on 9/28/2015..[As per conversation with PS on 10/7/15, on 10/6/15 all but 2 staff were trained as to the process to report areas that are not in good repair. Staff are to complete weekly staff report form and submit to PS on every Monday morning. PS will make necessary arrangements for physical site repairs. If repair to hole does not hold as this has happened in the past, local independent contractor will he hired to do a more permanent repair. Additional staff will be trained in process by 10/31/15.(AS 10/7/15)] 10/03/2015 Implemented
6400.112(c)The written fire drill record for the fire drill conducted on 2/26/15 did not include the exit route used. A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Staff will be retrained in proper documentation of firedrills. Program Specialist will check firedrills for proper documentation. 10/6/2015 [As per conversation with PS on 10/7/15, PS will review and sign off on fire drill up on review which was added to document. Staff were trained on 10/6/15, training document will be submitted to the department. Additional staff not present will be trained by PS by 10/31/15.(AS 10/7/15)] 10/03/2015 Implemented
6400.164(a)Polyethylene Glycol 3350 NF Powder for oral solution prescribed for Individual #1 is on the medication log with dosage instructions of 1 capful dissolved in liquid by mouth if no bowel movement in 3-4 days as needed. The medication prescription label reads 1 capful dissolved in liquid by mouth daily. 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. Pharmacy put wrong information on MAR. Orders were clarified by physician and re-entered correctly. Staff will check the medication label against the MAR upon medications coming into home and again prior to first administration time. Two label MAR verifications will be documented on health summary sheet. 10/1/2015 [PS will immediately review all Individuals' MARs and compare to prescription medication labels for accuracy and address as need. PS will review a sample of MARs and Medication labels weekly for the next 3 months to ensure accuracy. This will be completed at all community living homes. All staff continue to with required medication administration training as required and will receive additional training if errors or discrepancies are noted with the PS audits. Additions to POC was reviewed with PS on 10/7/15)](AS 10/6/15)] 10/03/2015 Implemented
6400.186(d)The ISP review documentation for Individual #1 dated 6/30/15, 3/31/15, 12/31/14, and 9/30/14 was not sent to plan team members. The ISP review documentation for Individual #2 dated 6/30/15, 3/31/15, 12/31/14, and 9/30/14 was not sent to plan team members. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Review documentation for the above quarterly dates with be given to SC and will have SC sign documentation stating the review documentation was received. 10/1/2015[As per conversation with PS on 10/7/15, PS developed a new form to have plan team members sign upon receipt of quarterly reviews; this form also includes the option to decline reviews. This will be done for all individuals in all community homes. (AS 10/7/15)] 10/03/2015 Implemented
SIN-00060794 Renewal 08/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(c)Staff person #1, date of hire 4/18/11, did not have a Pennsylvania criminal history record check completed until 3/9/12.The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire. Staff person #1 had submitted request on 4/07/11 for criminal history check. HR submits all requests through state representative and keeps request copies in file including copies of money orders sent. Staff #1 misplaced his results thus requiring a new request being sent 3/9/12. Correction is that HR will continue to copy and send out backround checks. HR will check weekly with supervisor to aquire completed checks from staff person for personnel file. 09/03/2014 Implemented
SIN-00196453 Renewal 11/09/2021 Compliant - Finalized
SIN-00160649 Renewal 08/13/2019 Compliant - Finalized
SIN-00140141 Renewal 08/17/2018 Compliant - Finalized
SIN-00049703 Renewal 04/25/2013 Compliant - Finalized