Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222362 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Temporary Direct Support Professional #1's date-of-hire is 1/21/23. Their PA criminal history check was completed through Checkr on 4/6/2022. The application for the Pennsylvania criminal history check was not submitted to the State Police as required by regulation.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. The temporary worker has not worked a shift for this Agency since 03/24/2023. The temporary worker was notified on 03/29/2023 that they are blocked from picking up any shifts for this Agency unless a completed and acceptable Pennsylvania State Police Criminal Background Check is provided. 03/29/2023 Implemented
6400.46(a)Temporary Direct Support Professional #1, date-of-hire is 1/21/23, did not have fire safety training prior to working with individuals. Temporary Direct Support Professional #2, date-of-hire is 1/25/23, did not have fire safety training prior to working with individuals.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.The temporary worker has not worked a shift for this Provider since 03/24/2023. The temporary worker was notified on 03/29/2023 that they are blocked from picking up any shifts for this Provider and if they return in the future they will complete the Provider's Fire Safety Training prior to working with any individuals. The Fire Safety Training will be completed by the temporary workers for all Provider homes prior to working any shift with individuals. The Home Managers will train the temporary workers on the evacuation procedures, responsibilities during fire drills, designated meeting place outside the building, smoking safety procedures, locations of fire extinguishers, smoke detectors and alarms for their assigned homes prior to allowing the temporary worker to work with individuals independently. 05/31/2023 Implemented
SIN-00204193 Renewal 04/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed of individual rights on 1-7-21, and then again on 2-11-22.[Repeated Violation 5/4/21 et al.]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.A residential Due Date Calendar has been created in which due dates are added to the calendar that Managers accept onto their calendar, due dates are set prior to the deadline. Individual Rights has been set on the calendar for January 4th 2023, with due stipulation of January 20, 2023. Training occurred on 5/4/22 which included the program specialist and members of the management team. This training was related to due date requirements for 6400 regulations, time management and calendar training. Training occurred on 5-13-22 related to the new process for cross checking the calendar and printing reminders to send out weekly. 05/04/2022 Implemented
SIN-00187282 Renewal 05/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A self-assessment will be completed for each home Between April 1st and July 30th, annually. Prior to the self-assessment being printed for use, the IDD Administrator will check the ODP website for the most current version and supply it to his House Coordinators and Program Specialist to complete the site parts of the assessment. The Program Specialist, Program Director and Program Manager will receive training on how to complete a self-assessment on 6/24/21 from 10am-3pm from the Regional Director. The Program Manager will review and advise House Coordinator and Assistant Program Directors on how to properly fill out the form on 06/29/21 during the weekly managers meeting. The Self Assessments will be completed on 6/30/21. 06/30/2021 Implemented
6400.77(b)The home's first aid kit does not include antiseptic. 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. On 5/20/21 the first aid checklist was updated to include antiseptic. Antiseptic put into the 1st aid supply kit on 5/20/21. The House Coordinator completed the revised First Aid Checklist for June noting that it included antiseptic. 06/10/2021 Implemented
6400.112(c)The written fire drill records for the monthly fire drills held from 12/2020 through 3/2021 did not included the exit routes 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. The provider has included in manager training that two categories are to be included in fire drills moving forward. 1. The route of escape. 2. The meeting location area. on 5/25/21. The Fire Drills from May and June had the exit route and meeting area, but was not specifically defined. The provider add " exit route used" to the form. On 6/17/21 a fire drill was conducted on this site, on 6/21/21 the site administrator filled out the correct form using the data from the 6/17/21 fire drill and signed off on it. 06/23/2021 Implemented
6400.141(a)Individual #1 had a physical examination on 10/30/2019 and then again on 3/29/2021.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The agency has hired a medical records coordinator who will track and recorded appointments for clients on the client tracking spreadsheet and be responsible for the compliance of client's medical appointments and ensuring that all forms are completed in their entirety and include all required supporting documentation. 06/23/2021 Implemented
6400.142(a)Individual #1's most recent dental examination was on 7/22/2019.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. An appointment has been scheduled for the individual on 7/22/21. 07/22/2021 Implemented
SIN-00167566 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's most recent assessment was completed on 8-17-18. 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. The Program Specialist will refer to our existing spreadsheet with due dates of assessments at the end of the month for the following month to determine which assessments are due for the following month. 2. The Vice President discussed with the Program Specialist about not crossing off the assessment as complete until the assessment has been signed by the Program Specialist and uploaded in our electronic medical record (12-19-19). 3. The Director will do a monthly audit following the due dates listed on the spreadsheet to ensure completion of assessments. [Immediately, upon hire and continuing at least annually, the CEO or designee shall educate the program specialist of the responsibilities of the program specialist position. Documentation of the trainings shall be kept. Documentation of the reviews by the Director and program specialist shall be kept. (DPOC by AES,HSLS on 12/24/19)] 12/19/2019 Implemented
6400.18(b)(2)Individual #1 was not administered Hydroxyzine Pamoate, 50 mg and Hyclate, 100 mg from 12-6-19 to 12-11-19 as prescribed. The medication error for failure to administer prescribed medications to Individual #1 was not reported in the Enterprise Incident Management system.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.Vice President discussed with the Program Director about agency¿s responsibility to report medication error in EIM which includes any omissions (12-18-19). 2. The agency will enter in EIM when there was failure to administer medications prescribed by the physician within 72 hours. [On 12/27/19, the Vice president of clinical services entered the medication error for Individual #1 into the EIM system. Immediately, upon hire and at least annually, the CEO or designee shall educate all staff person working in community homes of requirements of incident management and reporting process and their responsibilities of to ensure all incident, alleged incident and suspected incidents are reported timely through the Departments information management system. Documentation of all trainings shall be kept. At least monthly for 6 months and then continuing quarterly, the CEO or designee shall audit all the incident management process to ensure timely reporting. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/27/19)] 12/18/2019 Implemented
6400.165(c)Hydroxyzine Pamoate, 50 mg capsule, one capsule by oral route two times a day prescribed to Individual #1 was not administered from 12-6-19 to 12-11-19. Doxycycline Hyclate, 100 mg capsule, one capsule by oral route two times a day prescribed to Individual #1 was not administered from 12/6/19 at 5:00PM to 12/11/19.A prescription medication shall be administered as prescribed.1. Direct Care Staff will check the blisterpaks and compare it with the EMAR when the individuals arrive from a home visit if they brought their medications with them and report to supervisors immediately if any blisterpaks are missing or if any medications are missing in the blisterpaks. 2. The house manager will double check the blisterpaks and compare it with EMAR after the individual arrives home. 3. The house manager will immediately communicate with the pharmacy to replace any missing medication to prevent the individual from missing all prescribed medications. 4. Email was sent to all direct care staff regarding the need to compare blisterpaks to EMAR immediately after individual returns from home visit if they brought their medications home and to contact the on-call manager if any pills were found to be missing in a blisterpak or if a blisterpak was missing (12-23-19) [At least weekly for 3 months and continuing at least monthly, a staff person certified to administer medications shall audit all individuals current medication administration record, medications and physicians' orders to ensure medications are administered as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/24/19)] 12/23/2019 Implemented
SIN-00147373 Renewal 12/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency will use the correct self-assessment form during the months we are to conduct the self-assessment. (The incorrect form was used). The Vice President reviewed the correct form with the Program Specialist, Program Director, and Operations Director on 12/17/18 during the audit after finding out that the incorrect self-assessment form was used. The Program Specialist copied 7 correct self-assessment forms to prepare to do the self-assessments for each license homes which is due between April and July of 2019 on 12/18/19 after the audit ended and showed it to the Vice President before she flew back to Glenside. The Program Specialist also added on the google calendar as well as a visual calendar in the office to remind her that the inspection is due. Assistant Office Manager also added to her outlook calendar as April 1, 2019 as a reminder send the team e-mail letting them know that the residential team needs to start to work on the self-assessments for each license homes. The Operations Director will be responsible to check the ODP website to ensure that the program is using the correct self-assessment forms 1 month prior to the start of the beginning quarter. To ensure that the correct forms are completed, the Operations Director will check the forms again in April when the program specialist begins to work with the Program Director on the self-assessment form. May of 2019, the Vice President added to her white board and calendar reminder on outlook to inquire the self-assessments to review to ensure the correct forms were utilized so there is ample time to redo the assessment if the incorrect form was used. 01/11/2019 Implemented
SIN-00107592 Renewal 01/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at the bathtub in the bathroom measured 123°F at 10:33AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. Allen Schwender, Accounting and Real Estate Manager of Salisbury Behavioral health, has send a letter to Twin Oaks Condo Association requesting that they adjust the water heater to station at 120 degrees to meet our regulations. We are waiting for their response. Meanwhile, Toby Horn who is the maintenance personnel at our PAHrtners West location will do a weekly check on the water temperatures. Shall they exceed over 120 degrees again, Toby will communicate with his supervisor, Bill Chupcavich who is the Director of Maintenance for Salisbury Behavior Health along with Megan Lucsko, Program Specialist/Operations Director and Melissa Watson, VP for Residential Services. We will be in constant contact with the Twin Oaks maintenance department as well as the Condo Association.[Beginning immediately and continuing until the hot water temperature at all bathtubs and showers does not exceed 120°F for at least 2 weeks of daily measurement, a designated staff person shall measure and document the hot water temperature at the bathtub at least daily. If the hot water temperature exceeds 120°F during the daily measurements then line of sight supervision and assistance shall be implemented to ensure the individuals' safety while in the home. Operations Director is facilitating to close homes where the hot water is not able to be adjusted by the agency, the anticipated closure will take place in July, 2017. (AS 3/14/17)] 02/16/2017 Implemented
SIN-00065417 Renewal 11/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 8/10/14; however, the certificate of compliance expired on 10/18/14.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Agency will complete self-inspections within the appropriate timeframe - 3 to 6 months prior to expiration date of certificate of compliance. Timeframe has been noted on agency calendar. 06/18/2015 Implemented
6400.71The telephone number of the nearest hospital was not located on or by the telephone with an outside line.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. Telephone number of hospital has been added to emergency list by telephone with outside line. [The program specialist or designee will audit the content and location of the emergency phone list in each community home monthly. (CHG 12/22/14)] 11/18/2014 Implemented
SIN-00052547 Initial review 09/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)On 9/27/13, the first aid kit did not contain a pair of scissors.(b) 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. While the inspector was still at the site, the missing scissors were put into the first aid kit. [The program specialist will audit the first aid kit every two weeks to ensure it contains all of the required items. 10/15/13 CHG] 10/11/2013 Implemented
6400.110(a)On 9/27/13, the home did not have an audible smoke detector. The home was equipped with operable strobes and bed shakers in each bedroom.(a) A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. While the inspector was still at the site, an audible smoke detector was installed. This was in addition to the smoke detectors already installed that shake the bed so that the Deaf individuals residing in the home will be alerted in the event of fire during the night. Also we have installed smoke detectors with strobe lights which also automatically go to a monitoring station so that in the event of fire, the local fire dept and police dept will be alerted. 10/11/2013 Implemented
SIN-00127929 Renewal 01/16/2018 Compliant - Finalized
SIN-00100429 Unannounced Monitoring 09/01/2016 Compliant - Finalized
SIN-00087763 Renewal 12/21/2015 Compliant - Finalized