Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217356 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)On 1/11/2023 the window screen of the window located in the second-floor hallway has a two-inch rip on each side. Screens, windows and doors shall be in good repair. Screens were repaired/replaced on 1/11/23, by the Operations Director. this brings 6400.72(b) into compliance. [Documentation of installation of replaced screen, via photograph, was received on 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/18/23, was received 3/16/23 and reviewed 3/22/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/10/2023 Implemented
6400.72(c)On 1/11/2023 the exit door located in the basement of the home does not have an operable lock. Outside doors shall have operable locks.New exterior lock was placed on basement door, once approval from Landlord was given. This assured compliance with 6400.72(c) completed on 1/12/2023 [Documentation of installation of operable locking mechanism, via photograph, was received on 3/16/23 and reviewed 3/17/23. Documentation of quarterly monitoring form, dated 2/18/23, was received 3/16/23 and reviewed 3/22/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/01/2023 Implemented
6400.112(c)The written fire drill record for the fire drill held on 1/28/2022 does not include the amount of time it took for evacuation. The record states "5:00 PM" for the amount of time it took for evacuation.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. Residential Manager met with staff that completed drill dated on 1/28/2022, to review the regulation of 6400.112 Evacuation time. Explained the importance of reviewing the documentation prior to submitting in fire drill log. [Documentation of staff training for fire drill documentation, dated 1/14/23, along with a blank fire drill form was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/28/2023 Implemented
6400.142(g)Individual #1's dental hygiene plan was completed on 6/15/2021 and then again on 9/1/2022. This exceeds the annual requirement.A dental hygiene plan shall be rewritten at least annually. A refusal document was submitted to Licensing inspectors the last day of inspection for both his Dental Exam and Dental hygiene Plan, He went for next scheduled appointment on 9/1/2022, Documentation of refusal sent on 1/12/2023. [Written dental hygiene plan for Individual #1, updated 9/1/22, was received on 3/16/23 and reviewed 3/17/23. DPOC by HDKP, HSLS, on 3/22/23]. 02/03/2023 Implemented
6400.214(b)On 1/11/2023 Individual #1's most recent assessment and psychological evaluation were not present at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. On 1/11/2023, a RESIDENTIAL RECORDS binder was created: Binder contains Individual Demographics (ID Sheet), individual Assessments, most recent phycological evaluation, annual physical, dental hygiene plan, recent incident reports(90days) was placed in all service locations, this will assure compliance with 6400.214(b) 01/11/2023 Implemented
SIN-00167333 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Self-Assessment for Race Hill Street, completed beginning on 8/23 and ending on 8/30, did not include the year and was left blank in the following areas: 6400.19a6 through 6400.21e and 6400.188a through 6400.188d. The Self-Assessment for Hamilton Street, completed beginning on 8/3/19 and ending on 8/30/19 was left blank in the following areas: 6400.50b through 6400.51a5 and 6400.141c15 through 6400.142f. The Self-Assessment for Penn Street, completed beginning on 8/3/19 and ending on 8/29/19, was left blank in the following areas: 6400.31a through 6400.31c, 6400.32o through 6400.32q. 6400.42 through 6400.43b4 and 6400.50b through 6400.51a5. The Self-Assessment for Hawthorn Street was not dated; therefore, compliance could not be measured and was left blank in the following areas: 6400.181a through 6400.181f, 6400.182a through 6400.182b, 6400.184(8) through 6400.185(1), 6400.189a through 6400.190c and 6400.191 through 6400.208f.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Valley Advantages CEO will designate the Residential Manager to perform all Self-Assessments, This delegation of duties will assure multiple executive level staff are preparing and reviewing Self-Assessments to assure completion of all regulatory areas including date and 6400.19a6 through 6400.21e and 6400.188a. The CEO or Designee will monitor/review self assessments in 2020. [Documentation of reviews of the self assessments shall be kept and completed prior to 3 months before the expiration date of the agency's certificate of compliance. (DPOC by AES,HSLS on 12/26/19)] 12/23/2019 Implemented
6400.18(a)(13)On 11/2/19, at 12:00AM, during a shift change and staff debriefing, Direct Service Worker #2 reported, to Direct Service Worker #1 and Direct Service Worker #3 that s/he told Individual #1 s/he could not go for a van ride unless s/he took a bath. In addition, Direct Service Worker #2 reported that s/he gave Individual #1, Direct Service Worker #2's personal cigarettes under the condition that Individual #1 cleaned. Direct Service Worker #2 stated that Individual #1 exhibited verbally aggressive behaviors that Direct Service Worker #2 failed to document because s/he didn't care. Direct Service Worker #1 reported the incident to the agency's incident manager on 11/7/19. An incident with the primary category: Rights violation and Secondary Category: Misuse of Restrictive Intervention was entered into the Enterprise Incident Management system on 11/7/19.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: A violation of individual rights.DSP.Smith,l received ODP Individual Rights Orientation training and received certification on 11/7/2019. Service location will received additional psychical site monitoring and documentation monitoring, Responsible party is Amanda Everettt, Ps and Chelsey Davenport , this monitoring in ongoing, DSP, Vodko, R received training on Recognizing, Reporting Abuse, Neglect and Exploitation. Completed on 11/11/2019 Preventative Actions: All new hires will receive Individual Rights training and Recognizing and Reporting Abuse Neglect, Exploitation thru ODP Web Orientation Series, prior to working directly with HCBS individuals. [Documentation of all aforementioned trainings shall be kept. (DPOC by AES,HSLS on 12/26/19)] 11/11/2019 Implemented
SIN-00088509 Renewal 01/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certificate of compliance has an expiration date of 12/5/15; the self-assessment was completed on 9/28/15. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The CEO reviewed regulation 6400.15(a) in regards to self-assessments. Valley Advantages will monitor time frames in which the regulation must be completed, assuring for 2016 all self assessments will be completed between 6/5/2016-9/5/2016. [Immediately, CEO will develop and implement a system to alert as to when the self-assessment is due to be completed. CEO will monitor the alert system and review self-assessment to ensure timely completion. (AS 3/16/16)] 06/05/2016 Implemented
6400.44(b)(1)Individual #1's assessment, dated 3/27/15, was not completed by the Program Specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments. Valley Advantages in now aware of regulation 6400.44(b)(1) in regards to the Program Specialist completed the assessment. Regulation 6400.44(b)(1) was added to the Program Specialist Job Duties. See attachment 0001-D. The CEO will conduct random audits of the Program Specialist File to assure compliance with all 6400 Regulations. [Individual #1's assessment was signed as completed by the Program Specialist. Immediately and continuing at least quarterly, CEO will review all individuals' current assessments to ensure the completion by the program specialist. Documentation of reviews shall be kept. (AS 3/16/16)] 01/21/2016 Implemented
6400.71The telephone numbers for the nearest hospital and ambulance was not on or by the telephone in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Valley Advantages LLC Corrected Emergency numbers to include the nearest Hospital and ambulance at all locations. See attachment 0001-C,. The CEO will conduct quarterly audits to assure compliance with all 6400 regulations.[Documentation of all audits shall be maintained. (AS 3/7/16)] 01/30/2016 Implemented
6400.112(d)The evacuation time for the fire drill held on 7/25/15 was 2 minutes and 33 seconds. The evacuation time for the fire drill held on 9/15/15 was 2 minutes and 47 seconds. There is not a extended evacuation time specified in writing by a fire safety expert. 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. Valley Advantages reviewed regulation 6400.112(d) with all Direct Support Professionals, explained the importance of timely evacuation. Valley Advantages Administration will participate in future Fire Drills to work with Direct Support Professionals in obtaining the required 2 minutes 30 seconds regulation. [As reviewed with CEO on 3/10/16, monthly unannounced fire drills shall be held during normal staffing conditions and not when additional staff persons including Valley Advantages Administration are present. CEO will inquire with staff conducting the fire drill which exceeded the required evacuation time as to get there input as to how to ensure all staff and individuals evacuate within required times. CEO will conduct education, training and staffing changes to ensure all individuals are be able to evacuate the entire building within the required timeframes. CEO will review all fire drill records at least monthly until all fire drills in all community homes are conducted with the required evacuation times for at least 6 months, quarterly reviews shall continue thereafter. Documentation of all reviews, trainings, education shall be kept. (AS 3/16/16)] 01/21/2016 Implemented
6400.112(g)There were no fire drills held on Friday, Saturday or Sunday from January 2015 through December 2015. Fire drills shall be held on different days of the week and at different times of the day and night. Valley Advantages reviewed the Fire Drills for all locations and realized the deficit in weekend Fire Drills. The House Supervisor will train and supervise Friday, Saturday or Sunday Fire drills randomly thought out the calendar year to assure compliance with 6400.112(g). [As reviewed with CEO on 3/10/16, monthly unannounced fire drills shall be held during normal staffing conditions and not when additional staff persons including Valley Advantages Administration are present. CEO will review all fire drill records at least monthly to ensure all fire drills in all community homes are conducted on different days of the week and at different times of the day and night for at least 6 months, quarterly reviews shall continue thereafter. Documentation of all reviews shall be kept. (AS 3/16/16)] 01/30/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members for Individual #1 of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Valley Advantage program Specialist sent the notification to decline the ISp Review as defined in 6400.186(e) to individual #1 team. Regulation 6400.186(e) was added to the Program Specialist Job Duties. CEO will conduct quarterly audits to assure compliance with all regulations [On 3/21/16, Individual #1's team was notified of the option to decline the ISP review documentation. Immediately the program specialist will review all individuals' records including ISPs, invitation letter and other documentation to ensure all plan team members are notified of the option to decline ISP reviews documentation of the notifications shall be kept. At least quarterly, CEO will conducts checks of all individual records to ensure the plan team members for all Individuals are notified of the option to decline the ISP reviews. Documentation of the record reviews shall be kept. (AS 4/8/16)] 01/30/2016 Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Valley Advantages reviewed all individuals records and made necessary corrections. to assure compliance with regulation 6400.213(1)(I). Corrected records will become the template to assure continued compliance. CEO will conduct quarterly audits to assure compliance with all 6400 regulations.[Individual #1's record was updated to include "N/A glasses." Immediately, CEO will review all individuals' records to ensure identify marks for all individuals is accurately included in the record and updated. At least quarterly audits of the records will be conducted by the CEO to ensure all personal information including identify marks is accurately included in all individuals' records. (AS 3/16/16)] 01/21/2016 Implemented
SIN-00092018 Unannounced Monitoring 01/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Direct Service Worker #1, employed from 10/5/15 to 1/4/16 was physically aggressive, rough, and yelled at Individual #1. After Direct Service Worker #1 and Direct Service Worker #2, employed from 9/29/15 to 12/29/15, worked together, unexplained bruises were noticed on Individual #1. Reportedly, Direct Service Worker #1 would "take (his/her) frustrations out on (Individual #1). Push (his/her) fist into (Individual #1's) back." Direct Service Worker #3, employed from 8/14/14 to 12/30/15 was witnessed putting his/her "arm around (Individual #1's) neck when (Individual #1) wouldn't get up, similar to a choke hold." Individual #1 would physically shake when (Direct Service Worker #1) came into the house. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Valley Advantages CEO has reviewed Pennsylvanian Department of Human Services Bulletin dated may 7, 2015, which defines the Adult Protective Services Act(Act 70). The CEO has conducted training with All Valley Advantages Employees in regards to The APS Law and Valley Advantages reporting requirements for incidents not covered in the APS law. This training will be implemented with all new Employees and annually there after.[Within 90 days or receipt of the plan of correction, all staff working with individuals living in community homes shall be trained by an outside source in abuse including prevention, definitions, reporting and treating individuals with dignity and respect. (AS 5/31/16)] 05/06/2016 Implemented
6400.18(c)Over the course of the Department's investigation, several Direct Service Workers reported being aware of physical and verbal abuse towards Individual #1 on numerous occasions since September 2015. Physical abuse report, Incident number 7962081 was entered into HCSIS on 12/3/15.The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. Valley Advantages CEO has reviewed Pennsylvanian Department of Human Services Bulletin dated may 7, 2015, which defines the Adult Protective Services Act(Act 70). The CEO has conducted training with All Valley Advantages Employees in regards to The APS Law and Valley Advantages reporting requirements for incidents not covered in the APS law. This training will be implemented with all new Employees and annually there after. Signature logs and Training material will be forwarded [Within 90 days of receipt of the plan of correction, the CEO will develop, implement and train staff on policies and procedures to ensure reporting is completed within the required timeframes. Documentation of trainings shall be kept. (AS 5/31/16)] 05/06/2016 Implemented
Article X.1007An administrator or employee who has reasonable cause to suspect that a recipient between the ages of 18-59 with a disability is a victim of abuse, neglect, exploitation or abandonments shall immediately make a report in accordance with Adult Protective (APS) Law (Act 70). Since September 2015 there were numerous occasions of suspected incidents of physical abuse and verbal abuse against Individual #1 which were not reported in accordance with the Adult Protective Services Law (Act 70).When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Valley Advantages CEO has reviewed Pennsylvanian Department of Human Services Bulletin dated may 7, 2015, which defines the Adult Protective Services Act(Act 70). The CEO has conducted training with All Valley Advantages Employees in regards to The APS Law and Valley Advantages reporting requirements for incidents not covered in the APS law. This training will be implemented with all new Employees and annually there after..[Within 90 days of receipt of the plan of correction, the CEO will review the adult protective service section of dhs.pa.gov website to develop an updated training or utilize provided trainings to ensure all staff are trained on APS mandatory reporting utilizing the Mandatory Reporter Informational Guidance section (handout) updated March 2016 and other information. Along with the training, all staff shall receive a copy of the Mandatory Reporter Informational Guidance and a copy shall be available at all community homes. Documentation of trainings shall be kept. (AS 5/31/16)] 05/06/2016 Implemented
SIN-00071886 Renewal 01/05/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(10)Individual #1's monthly reports from December, 2013 through September, 2014 did not include a Program Specialist's signature or date of the reviews.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes.The HR Director reviewed with the Program Specialist the requirements of the position. Valley Advantages (CEO) will monitor the Program Specialist to assure accurate and timely completion of regulation 6400.44(b)(10) 01/12/2015 Implemented
Article X.1007Valley Advantage, LLC is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #1 had been hired provisionally, and began working with individuals in the community home on 8/8/14. The provider did not request a criminal background check in accordance with OAPSA until 8/11/14. When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Valley advantages will follow OAPSA Act 32 regul;ations in regards Criminal clearance. Valley Advantages policy will assure proof of request for Criminal Clearance prior to the staff working Direct Care with any individual. [The CEO and any staff persons involved in the hiring process will complete the OAPSA and criminal background check online training provided through the Department of Aging within 30 days upon receipt of the plan of correction. (CHG 1/26/15)] 01/18/2015 Implemented
SIN-00127854 Renewal 01/18/2018 Compliant - Finalized
SIN-00106661 Renewal 01/17/2017 Compliant - Finalized
SIN-00064351 Initial review 06/10/2014 Compliant - Finalized