Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186100 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Criminal Background check was not completed until 4/13/2021 and the staff #3 was hired on 1/8/2021. The criminal background check must be submitted within 5 days of hire.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. We have provided the entire agency staff with the New Employee Check List for New Hires, as our primary Administrative Staff who implemented that process was out sick due to Covid-19. This process has now been updated for compliance wit the regulation timeframe within 5 days of date of hire. 05/18/2021 Implemented
6400.62(a)There was a bottle of Clorox bleach located in the kitchen cupboard of the basement kitchen. Staff reports that the basement door is always locked. At the time of the inspection the basement door was not locked. Poisons shall be locked up.Poisonous materials shall be kept locked or made inaccessible to individuals. The Agency utilized 2 Administrative Staff for the video walk through of the homes with the ODP Inspector on the phone. This house was unoccupied as staff and individuals were in the community for activities. Admin Staff 1 entered empty house with phone video operating with ODP Inspector on the call, Admin Staff 2 entered house several minutes after Staff1. Admin Staff 1 asked Admin Staff 2 to unlock all doors, the medications and the First Aid Kit for the inspection process. We first went over the medications that had been placed on the kitchen table, the first aid kit, and then proceeded to complete the walk through. In the future we will maintain keeping all areas and items locked until the inspector is at the lock location to view the key unlocking the door and items. 04/22/2021 Implemented
6400.141(c)(1)The individual physical exam should include the medical history.The physical examination shall include: A review of previous medical history. The agency is including the previous medical history, per regulation's, within the document itself rather than attachments that accompany the document. Correction specific to this individual as well as agency wide to every individual in care. 05/18/2021 Implemented
6400.141(c)(9)The individual physical exam should include a prostrate exam being that individual #1 is over 40 years old.The physical examination shall include: A prostate examination for men 40 years of age or older. The agency is ensuring that edited version of the Annual Individual Physical is utilized for greater clarity in the performance of medical services for this and all individuals in care moving forward. In this case the Prostate Examination was recorded by the PCP on another form for the same date. The previous check system on the Physical itself recorded prostate as normal but revision of the document will provide greater clarity. 05/18/2021 Implemented
6400.181(d)The annual assessment should include signatures of the program specialist and individualThe program specialist shall sign and date the assessment. The agency has secured the Program Specialists signature on this and all other Individual's annual assessments with the transmittal letter to the Individual as proof that the individuals were made aware of the results of the assessment. 05/18/2021 Implemented
6400.166(a)(10)Individual #1 is prescribed Erythromycin OD and the MAR states to apply 1cm to both eyes once weekly on Saturday at bedtime. The time listed on the MAR is 8am. The pharmacy label does not specify a designated time. The MAR directions contradicts with times.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The error specific to time listed on the Medication Administration Record has been corrected for this individual and we reviewed all other individual's MAR's for possible errors, none found. The Admin Review Team has been made aware and will proceed with a heightened vigilance to reviewing this area. 05/18/2021 Implemented
6400.166(d)The directions of the prescriber shall be followed. The individual's medication Erythromycin does not specify what time of the day it shall be administered on the MARS.The directions of the prescriber shall be followed.The error specific to time of day on the Medication Administration Record has been corrected for this individual and we reviewed all other individual's MAR's for possible errors, none found. The Admin Review Team has been made aware and will proceed with a heightened vigilance to reviewing this area. 05/18/2021 Implemented
SIN-00130814 Renewal 03/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The well water was tested on 10/19/2017. It wasn't tested again until 1/29/2018, which exceeds the 3 month 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.Water tests performed on January 29, 2018 were not conducted in a timely fashion due to winter weather conditions causing numerous power failures in our area. These power failures affected our electronic reminders including water testing. This was noticed when we checked our physical documentation on January 29, 2018 and noted that the electronic reminder was off. The tests were immediately carried out. Going forward in addition to the electronic reminder a hard copy calendar has been implemented. 03/06/2018 Implemented
SIN-00089395 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Water testing was done on 1/20/2015. It was tested tested again until 5/7/2015, which exceeds 3 months.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 manual calendar has been modified. In addition, an electronic calendar has been created and will be maintained to identify tests and provide alerts prior to the test due dates to foster timely completion. The water test wll be completed and recorded by the Program Manager prior to the due date. The Deputy Director of Operations will check for compliance including results and date. 04/13/2016 Implemented
SIN-00071142 Renewal 02/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)Individual #2 did not have a review of his ISP every 3 months. The following reviews occurred for individual #2: annual on 3/12/2014, a Quarterly review on 8/7/2014, 11/4/2014, and on 2/10/2015. 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. Wakefield Cottage's Program Specialist will complete an ISP review of the services and expected outcomes in the ISP for the individual every 3 months. The individual's next 3 month review will be conducted in May 2015 and again in August 2015, November 2015, and February 2016. 05/08/2015 Implemented
SIN-00170292 Renewal 02/27/2020 Compliant - Finalized