Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233647 Renewal 10/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Individual #1 has not participated in the home's fire drills from November 2022 to October 2023. Documentation from a Certified Registered Nurse Practitioner on 9/30/22 and 5/12/23 indicated Individual #1 is exempt from fire drill because of physical and mental disabilities. 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 employe 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. The person supported (Individual #1) is a 61 year old man who is diagnosed with severe intellectual disability and cerebral palsy. (Individual #1) is bedridden and requires full physical assistance in all aspects of his life.(Individual #1) is incontinent and wears Depends at all times. (Individual #1) must be changed/repositioned every two hours. [Individual #1] receives only bed baths and also utilizes bath in a bag wipes. [Individual #1] requires full physical assistance for dressing. Due to the extent of his contractures, he wears only a shirt and socks. His shirts are cut up the back for easy dressing. [Individual #1] relies on staff to feed him and requires a pureed diet with honey thickened liquids. JG was in hospice care for quite some time. His physical decline became stable and he was discharged from the care of Family Hospice in April 2023. They will resume services as needed. Both hospice and primary care medical supports recommend that due to [Individual #1's] physical condition that it would be both painful and unsafe for [Individual #1] to evaluate the home during fire drills. (Verification to follow via email to ODP) There is a high likelihood that [Individual #1] would be injured should staff try to remove him from his bed for any reason. If emergency care is needed, [Individual #1} requires an ambulance for transport to the hospital. As such, a request for a waiver of regulation 55 PA Code Chapter 6400.112(d) will be submitted on form DP 1087 ¿Request for Waiver of Regulation¿, The form and accompanying documentation will be submitted via electronic mail to The person supported/their family will receive a copy of DP-1087 prior to or at the same time as submission to ODP. 11/17/2023 Implemented
6400.181(a)Individual #2's annual assessment was completed 6/30/22 then again 8/1/23. 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 Specialist completed RR¿s assessment so that it could be submitted 30 days prior to the ISP meeting date. While focusing on this date, she did not take into consideration that the assessment also needs to be within 365 (380) days of the previous one completed. I reviewed this error with her on 11/8/23 and reviewed the RCG page 107, which discusses regulation 181(a) in full. (Verification to follow via email to ODP). Specialist states that this error will not occur again. 11/13/2023 Implemented
SIN-00070349 Renewal 10/21/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The psychiatric medication reviews for Individual # 1 did not have the medications listed, the dosage, and the reason for prescribing the medications for the following dates: 9/18/13, 12/11/13, 2/26/14, 5/7/14, and 7/23/14. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The CH Supervisor discussed these concerns with the attending psychiatrist and he has agreed to complete the form that we provide. During the last psychiatric appointment the psychiatrist completed the form in its entirety. All required information was include on the form. He understands the need for all of this information to be completed for each subsequent visit. [Program Specialist or Designee will monitor the completion of the psychiatric medication review forms monthly to ensure they contain all required information. (CHG 1/114/15)] 11/03/2014 Implemented
SIN-00178295 Renewal 10/14/2020 Compliant - Finalized
SIN-00125997 Renewal 12/12/2017 Compliant - Finalized