Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228789 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Floors, walls, ceilings, and other surfaces shall be in good repair. At the time of inspection, there were 6 separate sections of the beige tile of the kitchen counter edges that were cracked. The sections ranged from being cracked in section of approximately 1 inch to up to 8 inches.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted in MaintainX for maintenance to determine if the countertop can be repaired or is it has to be replaced. 10/18/2023 Implemented
6400.81(k)(6)Individual #1 did not have a mirror in their bedroom, and it was not documented in their Individual Support Plan that they did not want to have one.In bedrooms, each individual shall have the following: A mirror. Futures will purchase a mirror. 10/20/2023 Implemented
6400.141(c)(14)Individual #1's physical examination dated 2/1/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section of the examination was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Specialist will review all annual physicals before they are uploaded to agency eHR. If any information is missing the physician will be contacted. 10/18/2023 Implemented
6400.32(r)An individual has the right to lock the individual's bedroom door. Individual #1 did not have a lock on their bedroom door.An individual has the right to lock the individual's bedroom door.Futures will communicate with all individuals and guardians who have opted to not have locks on their bedroom doors in an effort to help them make informed decisions. Futures will recommend all doors have locks on them and ensure all parties that staff will have a key on their person in case of emergency. If the person or guardian are adamant, they do not want a lock then the program specialist will request the ISP be updated. 10/31/2023 Implemented
6400.51(b)(1)Staff #1's did not receive orientation training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Staff #1's date of hire is 4/18/23 and they did not receive training until 5/23/23 and 6/5/23 in the training area.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Orientation training is scheduled by our training coordinator upon hire and communicated with the program manager and program specialist. Communication is provided to the program manager and program specialist. The training coordinator notifies both when a staff did not attend their scheduled training. The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled. If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. 11/14/2023 Implemented
6400.51(b)(2)Staff #1's did not receive orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Staff #1's date of hire is 4/18/23 and they received training on 6/5/23 in the training area.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.The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled. If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. 11/14/2023 Implemented
6400.51(b)(3)Staff #1's did not receive orientation training on Individual rights during orientation training. Staff #1's date of hire is 4/18/23 and they did not receive training until 5/23/23 in Individual Rights.The orientation must encompass the following areas: Individual rights.The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled. If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. 11/14/2023 Implemented
6400.51(b)(4)Staff #1's did not receive orientation training on recognizing and reporting incidents. Staff #1's date of hire is 4/18/23 and they did not receive training on recognizing and reporting incidents until 5/26/23 and 6/5/23.The orientation must encompass the following areas: recognizing and reporting incidents.The program manager and program specialist will be re-educated on the regulatory requirements for orientation training. In addition, they will be re-educated on agency procedures and policies when a staff does not attend training as scheduled. If a staff is unable to complete their training within 30 days they will not be permitted to work until it is completed. 11/14/2023 Implemented
6400.181(f)Individual #1's annual assessment was completed on 2/1/23, and there is no record or documentation that the program specialist provided the assessment to the individual plan team members at least 30 calendar days prior to an individual plan 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 specialist will submit the assessment via email and/or with a cover letter which will include the date of the submission. 08/29/2022 Implemented
SIN-00156779 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #1 had annual fire safety training on 10-06-17 and no fire safety training at all in 2018.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Employee was placed on administrative leave on 6/18/19. Employee did not work until she completed Fire Safety training on 7/15/19. Training records will be handed out monthly at staff meeting to employees. The Training pre-populates annual requirements as a reminder to the employee. Effective immediately. 08/05/2019 Implemented
6400.46(i)Staff #1's CPR certification expired. She was certified on 06-07-17 and not since.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Employee was placed on administrative leave on 6/18/19. Employee did not work until she completed CPR/First Aid training on 7/15/19. Training records will be handed out monthly at staff meeting to employees. The Training pre-populates annual requirements as a reminder to the employee. Effective immediately. 08/05/2019 Implemented
6400.112(e)Sleep drills were not conducted at this home every six months as required. A sleep drill was held on 10-22-18, then not again until 05-07-19. That particular sleep drill in May was reportedly held at 8:46PM.A fire drill shall be held during sleeping hours at least every 6 months. A form was developed for all community homes to assist frontline supervisors in tracking fire drills. The form includes the regulatory requirement to assist managers with assuring the requirement is met. 08/05/2019 Implemented
6400.181(a)Individual #3 had a late annual assessment. One was completed for her on 06-02-17, then not again until 07-27-18. 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. Program specialists will be trained on regulations 6400-181 through 6400.186. Our quality assurance specialist maintains a spreadsheet of when annual assessments are due. The current spreadsheet does not include the date of the previous assessment. This will be added to the spreadsheet. Quality assurance specialist will continue to send out monthly notifications assessments that are due. 08/05/2019 Implemented
6400.31(b)Individual #3's annual rights were signed late. They were signed 01-05-18 then not again until 01-24-19.The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.Program specialists will be trained on the annual requirements of individual rights. Specially that annual rights are date to date and there is no grace period permitted. 07/30/2019 Implemented
6400.52(a)(1)Staff #1 only had 19 hours of training for the 2018 calendar year.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Training records will be handed out monthly at staff meeting to all employees. This will allow the immediate supervisor and employee to track their required hours. Effective immediately. 08/05/2019 Implemented
6400.181(f)Individual #3's assessment was not sent to the SC and team at least thirty days prior to the ISP meeting. The meeting was held on 08/09/18 and the assessment was not completed nor sent until 07/27/18.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-00134441 Renewal 05/09/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature was measured at 125.9 degrees Fahrenheit in the hall bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water heater has been adjusted and temperature does not exceed 120F. Water will be tested weekly through December 31, 2018. Results of water test will be documented. 12/31/2018 Implemented
6400.110(b)The smoke detector located outside Individual #1's bedroom door was not operable when tested.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Smoke detector was replaced on 5/10/18. 05/10/2018 Implemented
SIN-00101221 Renewal 07/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The only antiseptic that was in the first aid kit was expired in December 2004. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Antiseptic was purchased on July 8. The PS/site managers will monitor expiration dates of medications and required items in the first aid kit on a monthly basis. 07/08/2016 Implemented
SIN-00178134 Renewal 10/06/2020 Compliant - Finalized