Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215071 Renewal 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff number 2: The date of hire is noted as 6/4/2022 and the criminal history check was requested on 6/20/22. This request date is greater than 5 days after date of hire.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 clearance for staff #2 was run in accordance with the regulation. Staff #2's hire date was 6/24/2022 (ATTACHMENT #1). The Pennsylvania State Police Response for Criminal History was run and disseminated on 6/20/2022, four days prior to her start date (ATTACHMENT #2). This information was shared with the licensing inspectors at the time of the exit review when it was discovered that there was an error when reviewing this information during the licensing visit (ATTACHMENT #3) 11/21/2022 Implemented
6400.64(b)There were four flies flying around the home during the physical site inspection.There may not be evidence of infestation of insects or rodents in the home. Quarterly Extermination services occur at this location, with a scheduled treatment occurring on 12/15/22. Associate Director contacted exterminating company and has increased service to this location on a monthly basis, effective January 19, 2023. 12/15/2022 Implemented
6400.65The second floor bathroom is ventilated by a skylight in the ceiling; however the skylight was not operational at the time of inspection.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Lead staff person contacted the landlord on 11/22/22 to report this as a maintenance issue. Landlord responded promptly and arranged for repair on 12/8/22 and was verified to be working by Associate Director on 12/8/22. 12/08/2022 Implemented
6400.110(e)The smoke detectors in this three story home operated independently but were not interconnected with each other.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Associate Director determined that the smoke detectors were not interconnected due to the Lead staff changing all of the batteries in the smoke detector due to Day Light Savings and this resulted in the system not being in connected. Associate Director corrected the issue immediately on 11/21/22 and verified that the smoke detectors were connected. 11/21/2022 Implemented
6400.144Individual #2's prescribed medication aprepiant 80 mg, with directions to take as needed for nausea was not present in the home for this individual to self-medicate with if needed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The individual in this home self-medicates and was aware that this was no longer an active PRN medication and shared this information with the licensing inspector. The Associate Director immediately confirmed with individuals¿ prescribing doctor that this medication was discontinued (ATTACHMENT # 8) and individuals¿ medication profile was updated to reflect this information on 11/21/22- the day the error was identified. 11/21/2022 Implemented
6400.181(c)Individual number 2 2/22/22 assessment does not list the sources of its information.The assessment shall be based on assessment instruments, interviews, progress notes and observations. A review of the Assessments completed for all individual's supported within the agency was reviewed and it was determined that this particular assessment was the only one missing the sources of information. This is an oversight of completion by the Community Support Liaison. The correction was made on this assessment after confirming the sources used to complete it and updated in the individuals¿ record. 12/02/2022 Implemented
6400.165(g)Greater than 90 days elapsed between Individual #2's 5/13/22 and 9/12/22 medication management appointments, a period of 122 days between them.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The appointment that was scheduled in 5/12/22 was not attended due to the individual refusing to attend and another appointment was not available until 6/13/22. The rescheduled medication management appointment was attended on 6/13/22 and the individual has successfully attended all follow-up medication management appointments since that time. 01/16/2023 Implemented
SIN-00153168 Renewal 02/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen stove hood had grease on its surface.Clean and sanitary conditions shall be maintained in the home. Upon recognition of this area of non-compliance, Values Into Action's Service Coordinator ensured all homes had thorough cleaning of range hoods that day (3/28/19). Within one week (by 4/4/19), Values Into Action Service Coordinator visited each home to ensure that range hoods were cleaned to expected standards. Values Into Action Clinical Support Director has revised the Daily Cleaning List to ensure this cleaning is completed on a regular and ongoing basis in the future; Service Coordinator has ensured the new cleaning list is at each home and is being completed by completing bi-weekly checks. A copy of this Daily Cleaning List is available through Attachment #1. 04/04/2019 Implemented
6400.76(a)The living room has a torn seat on the roll-out chair. Furniture and equipment shall be nonhazardous, clean and sturdy. Values Into Action's Service Coordinator spoke with the individual who lives in this home to explain the need to dispose of the old chair and purchase a new one; ongoing conversation and counseling around helping the individual understand the regulation that requires this was completed from the date of the inspection (3/28/19) until 4/9/19 when the individual agreed to purchase a new chair. (See Attachment #2 for receipt of new chair purchase). All homes were reviewed by Values Into Action's Service Coordinator and Customer Service Liaisons to ensure all furniture and equipment were clean, sturdy, and nonhazardous and no other areas of non-compliance found. Values Into Action's Service Director will ensure quarterly physical site inspections occur as scheduled and will ensure any support needed around the removal/replacement of furniture/equipment that is no longer in working order is completed with individuals as required. 04/09/2019 Implemented
SIN-00126273 Renewal 12/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)AT THE TIME OF INSPECTION THE EXHAUST PIPE HAD BECOME DETATCHED FROM THE DRYER CAUSING A LARGE BUILD UP OF LINT BEHIND THE DRYER WHICH PRESENTS A FIRE HAZARD. Floors, walls, ceilings and other surfaces shall be free of hazards.The Clinical Support Director instructed all staff to cease use of the dryer the day of inspection until the issue could be corrected to ensure no hazards to the individual. The property manager has since corrected this issue and the dryer is in working order again with all hazards removed. All Team Coordinators will be trained to specifically check for this type of hazard during the quarterly inspection process Values Into Action completes in each home to ensure ongoing compliance with this regulation. 01/16/2018 Implemented
6400.112(c)THE TIME OF THE FIRE DRILL CONDUCTED ON 11/22/2017 WAS NOT RECORDED ON THE FIRE DRILL RECORD.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 Team Coordinator who conducted this fire drill has received individual feedback regarding the error made on this form. The time has been updated on the form to make sure it is reflective of the fire drill time according to the Team Coordinator's time clock in for the date the drill was completed. A formal training for all Team Coordinators who perform fire drills will be conducted by the Clinical Support Director to ensure that all team members are properly trained and follow protocol moving forward. The Customer Service Liaison will complete a monthly audit of fire drills to ensure ongoing compliance with this regulation. 01/16/2018 Implemented
6400.141(c)(11)THE ANNUAL PHYSICAL EXAM DATED 12/14/2017 FOR INDIVIDUAL #1 DID NOT LIST ANYTHING FOR THE ASSESSMENT OF HEALTH MAINTENANCE NEEDS ON THE FORM.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This individual's physical form was updated on 12/19/17 by the primary care physician to ensure that this information was accessible on the annual physical form. All Team Coordinators responsible for coordination and oversight of medical appointments will receive further training around the application regulations from the Clinical Support Director on 1/16/18. Values into Action's nurse consultant will also complete regular audits of healthcare documentation to ensure ongoing compliance with this regulation. 01/16/2018 Implemented
SIN-00109999 Renewal 12/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were approximately twenty small dots of a brown substance on the wall at the top of the stairs on the second floor. Clean and sanitary conditions shall be maintained in the home. Values Into Action has ensured this stain from the Individual's exploding soda was properly cleaned and sanitized. Moving forward, Team Coordinator will ensure cleaning schedule is implemented within the home and will also complete home inspections quarterly at minimum to ensure ongoing compliance with this regulation. Service & Project Directors will perform periodic unannounced visits to monitor compliance as well. 03/23/2017 Implemented
6400.67(a)The screen door closer mechanism was broken and the piece that remained had sharp edges. Floors, walls, ceilings and other surfaces shall be in good repair. Values Into Action has ensured this piece of the door was removed to prevent any injury to staff/individual in the home. Moving forward, Team Coordinator will complete home inspections quarterly at minimum to ensure ongoing compliance with this regulation. Service & Project Directors will perform periodic unannounced visits to monitor compliance as well. 03/23/2017 Implemented
6400.171There were left over mashed potatoes in a sauce pan uncovered in the refridgerator. Food shall be protected from contamination while being stored, prepared, transported and served. Values Into Action has provided the Individual living in this home additional training around the importance of proper food preparation and storage to ensure safety, especially during this Individual's unsupervised time. Values Into Action has ensured that Individual has access to proper food storage equipment (sealable containers & markers for recording date in which food was prepared). Moving forward, staff in the home will ensure that this individual receives ongoing education and support to prevent recurrence and ensure his safety. 04/06/2017 Implemented
SIN-00197342 Renewal 11/22/2021 Compliant - Finalized
SIN-00181015 Renewal 11/18/2020 Compliant - Finalized