Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235145 Renewal 12/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.151(e)(13)(viii)Individual #1's most recent assessment completed on 9/30/23 does not identify Individual #1 to be financially independent. Yet, no one assists Individual #1 in keeping track of their petty cash. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property.Fixing the Immediate Problem: WHO: Lifesharing Specialist, will be responsible for implementing this plan of correction. WHAT: LSS will create an updated addendum to the original assessment to document Individual #1's ability to be financially independent. WHEN and HOW: LSS will complete the updated addendum to have a clear understanding of financial independence for individual #1's assessment by December 15th, 2023. LSS will complete this plan of correction by re-reviewing all other individual's assessments that are completed and add updated addendums if needed to document other individual's financial ability. 12/15/2023 Implemented
6500.151(c)The most recent assessment completed on 9/30/23 for Individual #1 did not document that the assessment was based on assessment instruments, interviews, progress notes, and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations.Fixing the Immediate Problem: WHO: The Lifesharing Specialist, will be responsible for implementing this plan of correction. WHAT: LSS will create an updated addendum for individual #1's assessment to document that the assessment was based on assessment instruments, interviews, progress notes, and observations. WHEN and HOW: LSS will complete the updated addendum for individual #1's assessment by December 15th, 2023. LSS will complete this plan of correction by re-reviewing all other individual's assessments that are completed and add updated addendums to document that the assessment was based on assessment instruments, interviews, progress notes, and observations. All updated addendums will be sent out to the team to show the most up to date addendum. 12/15/2023 Implemented
SIN-00218126 Renewal 01/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(b)The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. The licensing inspection document completed on 1/12/2023 was not the correct form submitted.The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance.Fixing the Immediate Problem: WHO: CEO will be responsible for implementing this plan of correction. WHAT: Focus Behavioral Health will complete the Self-Assessment Tool on the proper form. WHEN and HOW: The Family Living Specialist will complete the Self-Assessment Tool on the proper form by March 17, 2023, which will allow Focus Behavioral Health to implement other plans of corrections prior to the completion. The FLS will complete this plan of correction by re-reviewing and re-inspection individual files and site locations. The proper form will be obtained from ODP's direct website. 03/17/2023 Implemented
6500.23(a)An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home. Staff #1 is 19 yrs old and the criminal background check was not completed when they turned 18 yrs old.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home.Fixing the Immediate Problem: WHO: CEO will be responsible for implementing this plan of correction. WHAT: Focus Behavioral Health will need to obtain ages of all residents in a home and require background checks of all family members residing in the home over the age of 18. WHEN and HOW: A PA state background clearance was not found for Staff #1 during annual licensing. On 01/27/2023 a PA State Background Clearance was obtained for Staff #1. 02/27/2023 Implemented
6500.107(d)6500.107(d) -- A smoke detector shall be tested each month to determine if the detector is operative -- The Program Specialist is completing the monthly checks at the home late. The December 2022 wasn't checked until January 12,2023 according to the documentation.A smoke detector shall be tested each month to determine if the detector is operative.WHO: CEO will be responsible for implementing this plan of correction. WHAT: Focus Behavioral Health will require smoke detector logs to be completed on a monthly basis, as well as logs to be completed correctly. WHEN and HOW: Smoke Detector logs have been updated with the correct information on 2/2/23. 02/27/2023 Implemented