Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00198376 Renewal 12/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)There is no bath mat on second level bath tub. Bathtubs and showers shall have a nonslip surface or mat. Corrected same day as inspection. Tub mat was purchased and placed in tub on 12/15/2021. 01/31/2022 Implemented
6400.151(a)There is no up to date physical exam for Staff #1. The most recent exam is dated May 2018. A physical exam is needed every two years. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #1 is scheduled for physical exam with occupational health on 2/15/22. Documentation will be provided by the Human Resources Compliance Manager when the physical is completed. 02/15/2022 Implemented
6400.46(a)There is no fire safety training for Staff #1.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff fire safety training was located for 2020 and 2021. 12/31/2021 Implemented
6400.169(d)There is no trainer information or recertification date on the Medication Administration training for Staff #1. This information is needed on the annual practicum form.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Medication trainer will conduct a review either in person or virtually with Staff #1 and complete documents accurately. 05/31/2022 Implemented
SIN-00155707 Renewal 04/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)Located on the back porch was a large open trash can filled with trash.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The trash can without a lid was disposed off. All homes were checked for cans with lids. In the future, should a trash can no longer have a lid or if the lid is damaged, the trash can will be replaced with new trash can with a lid. 04/18/2019 Implemented
6400.112(d)The fire drill dated 9/9/18 documented the evacuation time as 2 minutes, 50 seconds.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 employee 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.Fire drills for all homes will be audited by PA Audit Specialist from the Risk Management department. Any errors will be addressed before the close of the month. Staff of the Hidden River location will be retained on the procedure of running a fire drill. All new staff will complete/run one supervised fire drill within their first 90 days of employment. This protocol was put into place beginning with the June 2019 new hire orientation. 06/20/2019 Implemented
SIN-00109589 Renewal 02/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff #5's record did not contain an FBI check or a Pennsylvania residency declaration document. If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. Staff #5 had an FBI check on 10/30/2017. As of 11/4/16, a designated member of the Human Resources department is responsible to ensure that all prospective employees who will have direct contact with individuals and reside outside of Pennsylvania, will have an application submitted for a Federal Bureau of Investigation criminal history record check in addition to the Pennsylvania criminal history record check, within 5 working days after person¿s date of hire. If the individual lives in Pennsylvania, a PA declaration page will be included in the staff member¿s file. This designated member of the Human Resources department tracks all application dates in order to verify compliance. 04/03/2017 Implemented
SIN-00095184 Renewal 12/22/2015 Compliant - Finalized