Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230976 Renewal 08/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)There was no documentation that Individual #1's assessment was sent to the team 30 days prior to the ISP 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.Director drafted chart with due dates for assessments (attachment #3) and instructions on how to record team notifications listed on chart. Email will be the timestamp to ensure team members receive assessment within 30 days of ISP meeting. Program manager/ program specialist trained on timelines on 9/26 (attachment #4). 09/26/2023 Implemented
SIN-00209958 Renewal 08/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The railing outside in front of the house was loose. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Railing was repaired 9.19.22 (attachment 1, photo) 09/19/2022 Implemented
SIN-00179649 Renewal 01/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)A plunger was in the bathroom, and was moved.Clean and sanitary conditions shall be maintained in the home. The plunger was moved to the hall closet, where it is currently kept. A memo was drafted to staff from the Residential Director, indicating that the bathroom plunger must be kept out of the bathroom, but must also remain accessible. This was corrected on 1/15/2020. All the Residential homes were reviewed, and there are no plungers in any of the bathrooms. The memo to staff and copies of the Program Supervisor's weekly site checklist have been submitted as supporting documentation, via email. 01/15/2020 Implemented
6400.110(e)The First and second levels of the home are interconnected to each other but not to the basement.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. The smoke alarms were checked by SBR's Maintenance Department immediately following the inspector's visit, and the detectors on all floors, including the basement, are interconnected. We are not sure why the interconnected detectors were not audible to the inspector, but a review of this home and all the homes in SBR's Residential Program were completed by our maintenance department; all of the interconnected smoke alarms are working properly in all of SBR's Residential homes. We have submitted a request via email to have this citation removed from our POC. 01/14/1920 Implemented
SIN-00144352 Renewal 11/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Staff person #1's date of hire 12/16/17, who resides outside of Pennsylvania, did not have a FBI criminal history check.If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.The proper code was updated, and the FBI criminal history record check was completed on 11/30/18. Receipt confirmation will be submitted with the POC (via email). 11/30/2018 Implemented
6400.141(c)(3)Individual #1's physical exam dated 1/5/18 did not include Immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. A letter was faxed to the individual's primary care physician requesting that they provide the missing information from the annual physical. (documentation will be submitted with the POC). At the moment, Individual #1 is hospitalized; a new annual physical will be scheduled upon his return to the program. Lastly, SBR is working on forming a committee, with our QM team to review annual physical requirements prior to the scheduled appointment, and the contents of the annual physical after it is completed. 11/30/2018 Implemented
6400.141(c)(11)Physical exam for individual #1 dated 1/5/18 did not include the assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals were left blankThe physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. A letter was faxed to the individual's primary care physician requesting that they provide the missing information from the annual physical. (documentation will be submitted with the POC). At the moment, Individual #1 is hospitalized; a new annual physical will be scheduled upon his return to the program. Lastly, SBR is working on forming a committee, with our QM team to review annual physical requirements prior to the scheduled appointment, and the contents of the annual physical after it is completed. 11/30/2018 Implemented
6400.141(c)(12)Individual#1's physical exam dated 1/5/18 did not include physical limitations.The physical examination shall include: Physical limitations of the individual. A letter was faxed to individual's primary care physician requesting that they provide the missing information from the annual physical. (documentation will be submitted with the POC). At the moment, Individual #1 is hospitalized; a new annual physical will be scheduled upon his return to the program. Lastly, SBR is working on forming a committee, with our QM team to review annual physical requirements prior to the scheduled appointment, and the contents of the annual physical after it is completed. 11/30/2018 Implemented
6400.141(c)(14)Individual #1's physical exam dated 1/5/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. A letter was faxed to the individual's primary care physician requesting that they provide the missing information from the annual physical. (documentation will be submitted with the POC). At the moment, Individual #1 is hospitalized; a new annual physical will be scheduled upon his return to the program. Lastly, SBR is working on forming a committee, with our QM team to review annual physical requirements prior to the scheduled appointment, and the contents of the annual physical after it is completed. 11/30/2018 Implemented
SIN-00093260 Renewal 06/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A bottle of Dial Antibacterial Hand Soap was found unlocked in the second floor bathroom and the label warned to call Poison Control if ingested. A bottle of Dial Antibacterial Hand Soap was found unlocked in the first floor bathroom and the label warned to call Poison Control if ingested. Poisonous materials shall be kept locked or made inaccessible to individuals.The hand soap was immediately disposed of, and new hand soap was purchased; the new hand soap does not include a Poison Control warning. A weekly site checklist has been implemented, and will be completed by both staff and the supervisor. The checklist includes monitoring the homes for exposed poisonous materials.The checklist will be reviewed twice a month by the Program Director. 06/30/2016 Implemented
6400.151(c)(4)Staff #1's annual physical dated 9/9/14 did not document medical problems. The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.The annual physical form was updated in 2015 to include a section for medical problems that may interfere with the health of individuals. The individual had a physical completed, on the new form, on 8/9/2016.[Within 30 days receipt of this plan of correction quality assurance or program designee will conduct an audit of medical forms for all individuals served to ensure that all required information is provided. Additionally, quality assurance or program designee will complete an review of incoming medical forms to ensure accurate completion of all required information. DD 11.21.16] 08/16/2016 Implemented
SIN-00062879 Renewal 03/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 refused dental examinations and health services. On 10/15/13 a periodontal and oral surgeon appointment, that was recommended, was not completed. The individual does not have a plan to address refusal or training to educate the individual of the need for health care services.(a) If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. In conjunction with the behavior specialist, a desensitization plan was completed on 3/21/14. The supervisor will review the plan with staff, prior to any dental appointments. A copy of the plan will be forwarded via email. 03/21/2014 Implemented
6400.186(c)(1)The monthly ISP reviews for individual #1 for the months of 2/14, 12/13 and 8/13, in accordance with the ISP dated 4/8/13-4/914, did not include progress/growth for outcomes to improve coping skills by decreasing anxiety.(c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Monthly reports will now include a summary of how Julius is progressing with this outcome, including dates and details from when he receives behavior support. This is effective 4/1/14. 04/01/2014 Implemented
SIN-00063594 Renewal 03/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 refuses dental examinations and health services recommended from an appointment completed on 10/15/13 to see a Periodontist and an Oral Surgeon. Both appointments were not completed. The individual does not have a plan to address refusal or training to educate the individual of the need for health care services.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. In conjunction with the behavior specialist, a desensitization plan was developed on 3/21/14. The supervisor will review this plan with all staff whom work with individual #1, and ensure that it is implemented prior to dental and medical appointments. Pertinent documentation has been submitted via email. Supervisor will ensure that the plan is being followed in advance of appointments by completing a monitoring of medical appointments and the individuals refusal rate. Changes to the plan will be made as needed in consult with the behavior specialist. 03/21/2014 Implemented
6400.186(c)(1)The monthly ISP reviews dated 2/14, 12/13 and 8/13, for the time period of 4/8/13-4/9/14, did not include progress/growth as it related to indivdual#1's outcome to improve coping skills by decreasing anxiety.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Each monthly report will include a summary of how the individuals are progressing with each outcome, effective 4/1/14. Pertinent documentation has been submitted via email. In addition, Supervisor will develop an auditing tool and randomly select a 10% sample to evaluate that all necessary information has been included in the monthly reports. 04/01/2014 Implemented
SIN-00192757 Renewal 08/18/2021 Compliant - Finalized
SIN-00074897 Renewal 03/31/2015 Compliant - Finalized