Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240823 Renewal 03/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)For staff 1 -- DOH 12/15/23, Date of request 12/27/2023An 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. On 3/27/2024, Halia's HR department obtained a previous Pennsylvania criminal history record check for staff1, which has been uploaded to the drop folder in compliance with 55 PA Code Chapter 6400.21(a). 03/27/2024 Implemented
6400.65There is no window or fan in the second-floor bathroom.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On March 26, 2024, Halia's maintenance personnel, under the supervision of the COO, installed a new exhaust fan in the second-floor bathroom. 03/26/2024 Implemented
6400.81(k)(6)For individual 3 - there is no mirror in the bedroom.In bedrooms, each individual shall have the following: A mirror. For Individual 3, there is currently no mirror present in their bedroom, as agreed upon by their ISP team for the individual's health and safety. On 3/27/2024, the team met with the behavior specialist, and it was decided that this modification would be documented in Individual 3's ISP by their Service Coordinator (SC). 03/27/2024 Implemented
6400.110(f)Individual 3 has profound hearing loss. This property has no operative fire alarm strobe lights or a bed shaker for this individual. Their fire safety needs are not being met. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Halia through its COO has secured a contract with KARTMAN Fire Protection Services to address this noncompliance. KARTMAN has scheduled to come to 939 Andrews Ave to install the fire alarm system equipment including strobe light and bed shaker by May 17, 2024 05/17/2024 Implemented
6400.111(c)Kitchen did not have an inspected fire extinguisher. An inspected fire extinguisher was removed from the living room and placed into the kitchen while the inspector was still on site. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). On March 17, 2024, the CEO acquired another inspected fire extinguisher for the kitchen. 03/17/2024 Implemented
6400.113(a)For individual 3 - A record of the completed fire safety training was not found in the record. 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. On March 17, 2024, Halia's program specialist conducted and completed fire safety training for Individual 3. 03/17/2024 Implemented
6400.142(f)For individual 3 - There is no documentation of a completed dental hygiene plan.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. On March 17, 2024, the Program Specialist updated the dental hygiene plan for Individual 3 and ensured that all individuals receive a written plan for dental hygiene. 03/17/2024 Implemented
6400.181(a)For individual 3 - The assessment is dated 12/1/23, which is more than 60 days from the date of admission, lapsing the required timeline. 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. On March 27, 2024, the Halia Program Specialist, under the supervision of the COO, received instruction and reviewed the regulation requiring completion of the initial assessment within 1 year before or 60 calendar days after admission to the residential home, with subsequent updated assessments annually thereafter. 03/27/2024 Implemented
6400.181(e)(10)For individual 3 - lifetime medical history was not found in the record.The assessment must include the following information: A lifetime medical history. On March 20, 2024, the agency's nurse completed Individual 3's lifetime medical history and placed it in his record for inspection. 03/20/2024 Implemented
6400.32(r)For individual 3 - The individual rights form does not include stipulation about the consumer's right to have a lock on their door.An individual has the right to lock the individual's bedroom door.On March 28, 2024, Halia's maintenance personnel, supervised by the COO, changed the lock on Individual 3's bedroom door. 03/28/2024 Implemented
6400.166(d)Individual 3 was prescribed Sunblock SPF 30, but medications included a sunscreen with an SPF of 100.The directions of the prescriber shall be followed.The agency's nurse has rectified this error by replacing the sunscreen as prescribed, instead of the initially provided SPF 100. 03/28/2024 Implemented
6400.183(c)For individual 3 - A record of the ISP meeting sign-in sheet was not found in the record.The list of persons who participated in the individual plan meeting shall be kept.On April 1, 2024, the COO received a copy of the individual's ISP meeting sign-in sheet from the SC and secured it in the individual's record. 04/01/2024 Implemented
6400.186Individual 3's ISP describes their profound hearing loss and indicates that their bed has a bed shaker and that their home is outfitted with fire alarm strobe lights. This property does not have operative fire alarm strobe lights nor a bed shaker for Individual 3. Their plan is not being implemented as written.The home shall implement the individual plan, including revisions.Halia through its COO has secured a contract with KARTMAN Protection Services to address the area of noncompliance (55 PA Code Chapter 6400.186). KARTMAN has scheduled to come out to 939 Andrews Ave to install the strode lights, bed shaker, and a Fire Alarm system by May 17, 2024. 05/17/2024 Implemented