Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00191309 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Individual #3 did not have a locking mechanism on his bedroom door.An individual has the right to lock the individual's bedroom door.The guardian of the individual does not want individual #3 to have a lock on his door. The PS has requested the SC update the ISP with this information. 10/01/2021 Implemented
6400.52(c)(1)Staff # 3 did not receive training in the application of person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.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.Futures training committee will develop a list of trainings that meet the 6600 regulations for annual orientation and training. The list will be shared with program specialists, frontline supervisors, and direct support professionals 10/15/2021 Implemented
6400.52(c)(2)Staff #3 did not receive training in the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse.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.Futures training committee will develop a list of trainings that meet the 6600 regulations for annual orientation and training. The list will be shared with program specialists, frontline supervisors, and direct support professionals 10/15/2021 Implemented
6400.166(a)(11)Individual #3's medication administration record did not include diagnosis or purpose for any of the prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Frontline supervisor will add the diagnosis to the instruction for each medication of the MARs for October. Futures MAR template will be updated to prompt for a diagnosis for each medication. The updated MAR will be available by November 1, 2021. 10/01/2021 Implemented
SIN-00156775 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers at all posted by the upstairs main phone near the kitchen (*corrected at time of inspection)Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. All Community Homes will continue to keep emergency numbers on the back of the cordless phone. In addition to this emergency numbers will be posted on the wall near the base of the phone. 08/09/2019 Implemented
6400.106Havens Road's annual furnace inspection was late. It was completed on 10/08/17, then not again until 11/13/18.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnaces in community homes will be inspected every October starting in 2019. The agency maintenance department will take the lead with scheduling the inspections. 08/05/2019 Implemented
6400.113(a)Individual #1last had fire safety training on 09/28/17. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Individual was trained on fire safety on 6/18/19. Program specialists will be trained on regulatory requirement pertaining to annual fire safety training for individuals in a 6400 setting. 07/30/2019 Implemented
6400.181(f)There is no documentation in Individual #1's file that indicates his assessment was sent to the SC and/or team at least 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program specialists will be trained on regulations 6400-181 through 6400.186. 07/02/2019 Implemented
SIN-00134437 Renewal 05/09/2018 Compliant - Finalized
SIN-00101218 Renewal 07/07/2016 Compliant - Finalized