Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00212799 Renewal 10/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At the time of the inspection, there was a green floor cleaner solution in an unmarked bottle.Poisonous materials shall be stored in their original, labeled containers. 6400.62(c) Christoff 1. At the time of the inspection, there was a green floor cleaner solution in an unmarked bottle. 2. The unmarked bottle was immediately removed from the home. 3. All other homes were found to be compliant with this regulation 4. Managers will inspect all homes on a weekly basis to ensure compliance of this regulation and sign off that all homes were inspected for this regulation 5. Staff will be trained by the License Compliance Managers¿, and/or General Manager on regulation 6400.62 by 12/30/2022. Attachment #2 12/30/2022 Implemented
SIN-00178855 Renewal 11/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency's self-assessment completed on 10/12/20 does not include a written summary of corrections.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Pa Code 6400.15 (c) 1. The agency self-assessment completed on 10/12/20 does not include a written summary of corrections for the identified violations. Corrections to violation were made on 11/6/2020. All violations will include a written summary of corrections shall be made and kept by the agency for at least 1 year by the agencys License Compliance Manager. 2. Other locations were found to have been in violation of this, violation was addressed with License Compliance Manager and corrected on 11/6/2020. 3. All staff will be trained on this regulation by CEO to ensure that all self-assessments remain in compliance with this regulation. All staff will be trained by 12/31/2020. 4. Self-Assessments will be reviewed on a yearly basis by License Compliance Manager and CEO. ATTACHMENT #6 11/06/2020 Implemented
6400.141(c)(15)Individual # 1's physical exam dated 07/28/20 does not include information on the Dietary needs of the individual. The space was left blank.The physical examination shall include:Special instructions for the individual's diet. Pa Code 6400.141 (c) (15) 1.Individual # 1's physical exam dated 07/28/20 does not include information on the Dietary needs of the individual. The space was left blank. 2. All other locations were incompliance with this regulation. This violation was addressed with Medical Coordinator and will be corrected by 11/16/2020. 3. All staff will be trained on this regulation by Medical Coordinator to ensure all physicals are properly documented and completed. All staff will be trained by 12/31/2020. 4. All physicals will be reviewed by Medical Coordinator on a yearly basis. ATTACHMENT #7 11/16/2020 Implemented
6400.181(e)(7)Individual # 1's assessment dated 10/29/20 does not include her ability to move away quickly from heat sources. The assessment reads that she can "stay away" from and "avoid" heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Pa Code 6400.181 (e) (7) 1. Individual # 1's assessment dated 10/29/20 does not include her ability to move away quickly from heat sources. The assessment reads that she can "stay away" from and "avoid" heat sources. Violation was corrected on 11/6/2020. 2. All other assessments were reviewed by the Program Specialist on 11/10/2020 and all others were found to be incompliance with this regulation. 3. The Vice President will review all assessments with Program Specialist on a yearly basis to ensure compliance. 4. Program Specialist was trained by Vice President on 11/9/2020 on regulation 6400.181 (e) (7) ensuring that all assessments read individuals ability to move away from heat sources. ATTACHMENT #8 11/06/2020 Implemented
6400.217Individual # 1's record does not include any signed releases of information for her external treatment provider, Alternative Community Resource Program.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Pa Code 6400.217 1. Individual # 1's record does not include any signed releases of information for her external treatment provider, Alternative Community Resource Program. 2. Other locations were found to have been in violation of this, violation was addressed with CEO and will be corrected by 12/31/2020. 3. All staff will be trained on this regulation by CEO to ensure all individuals have signed releases of information by 12/31/2020. 4. Individual releases will be reviewed on a yearly basis by License Compliance Manager and CEO. ATTACHMENT # 9 12/31/2020 Implemented
6400.31(b)Individual #1's individual rights notification form signed 09/08/20 does not include being informed of Regulation 32r which includes the right to have locks on doors.The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.Pa Code 6400.31 (b) 1. Individual #1's individual rights notification form signed 09/08/20 does not include being informed of Regulation 32r which includes the right to have locks on doors. 2. Other locations were found to have been in violation of this, violation was addressed with CEO and corrected on 11/9/2020. The CEO shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights yearly. 3. All staff will be trained on this regulation by CEO to ensure signed releases are completed on a yearly basis for all individuals. All staff will be trained by 12/31/2020. 4. Individual rights will be reviewed on a yearly basis by License Compliance Manager and CEO. ATTACHMENT #10 11/09/2020 Implemented
6400.166(a)(11)Individual # 1 is prescribed Clotrimazole Cre 1%. The reason for the medication is not listed on the MAR or the medication labelA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Pa Code 6400.166 (a) (11) 1. Individual # 1 is prescribed Clotrimazole Cre 1%. The reason for the medication is not listed on the MAR or the medication label 2. All other MAR¿S were reviewed by Medical Administrator to ensure each medication has a Diagnosis; all other homes were found to be incompliance with this regulation. 3. All staff will be trained on this regulation by Medical Administrator to ensure all homes remain in compliance with this regulation. All staff will be trained by 12/31/2020. 12/31/2020 Implemented
SIN-00137783 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no indication that a self-assessment was completed for 1553 Lower Christoff Street as there was no residential addresses recorded on the self-assessment forms. The legal entity address, which is different than all the residential home addresses, was recorded on all self-assessment forms.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. 1. The CEO trained Vice President on regulation 6400.15A on 09/04/2018 to have addresses properly identified on the self-assessment. 2. All other locations were not in compliance with this regulation. This violation was addressed by the licensor on 08/29/2018 during on-site inspection. 3. The President and Vice President and house team leads were trained on regulation 6400.15A by the CEO to ensure that all self-assessments will have the proper addresses listed with reference to Regulation 6400.15A. The President, Vice-President and House Team Leads will sign off on signature paper by 12/31/2018. 4. The CEO will review with the Vice President the self- assessments on a yearly basis to ensure compliance. 10/12/2018 Implemented
6400.67(a)-The kitchen drawers located to the left and the right of the stove, were very hard to open, getting stuck at some points. All the kitchen cabinets and drawers located on the same side as the stove/oven were not equipped with drawer knobs. The kitchen cabinet located to the lower, right of the stove would not close completely. The cabinet door was hanging lower due to not being attached to the cabinet base properly. -There were multiple purple stains on the carpet located in the same room as the dining room table. -The first floor bathroom sink drains very slow, allowing the sink to fill up with the water running. The spigot on the first floor bathroom sink was spraying water out in many directions. The water flow was not one solid stream.Floors, walls, ceilings and other surfaces shall be in good repair. 1. On 08/30/2018 a maintenance request was sent to the maintenance department and all items found to be out of compliance were fixed by 10/10/2018. 2. On 09/04/2018-09/08/2018 the quality compliance manager inspected all other homes. Maintenance forms were submitted on 09/08/2018. 3. All staff will be trained on regulation 6400.67a to include floors, walls, and ceilings and other surfaces will be in good repair. Staff will sign off on signature paper by 12/31/2018. 4. The quality compliance manager will on a weekly basis check all other individual¿s homes to make sure that everything is in good repair. The quality compliance manager will sign off on checklist to ensure that everything is in good repair starting on 11/01/2018. 10/12/2018 Implemented
6400.110(a)The smoke detector in the basement did not sound. The attic was kept shut with a padlock and a smoke detector is not located in the attic. The agency has the key to the attic thus granting them access to the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. 1. On 8-30-18 NSC maintenance installed an interconnected smoke detector in the basement. 2. The quality compliance manager checked all other locations to make sure that all interconnected smoke detectors work. This was completed on 09/04/2018. It was found that all other locations were in compliance. 3. All staff will be trained on regulation 6400.110a by the fire safety expert to make sure that there is always one interconnected smoke detector on each floor. Staff will sign off on training signature paper by 12/31/2018. 4. Immediately and continuing every month, all smoke detectors shall be checked by a designated staff person who is trained in the use of smoke detectors and fire alarms to ensure that there is at least one operable automatic smoke detector on each floor of all community homes. 10/12/2018 Implemented
6400.111(a)The attic was kept shut with a padlock and a fire extinguisher is not located in the attic. The agency has the key to the attic thus granting them access to the attic.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. 1. On 08/30/2018 the President turned back in the attic keys to the landlord, so no one has access to the attic. 2. On 09/04/2018 the Quality Compliance Manager checked all other homes that was not cited for 6400.111.a and found all other homes to be in compliance. 3. All staff will be trained on Regulation 6400.111.a to include that all floors will have a minimum of 2-a rating fire extinguisher. Staff will sign off on signature page by 12/31/2018. 4. The quality compliance manager will check on a weekly basis to ensure that there is at least one fire extinguisher with a 2-a rating on each floor in all individual homes. The quality compliance manager will sign off on checklist to ensure compliance with this regulation starting on 11/01/2018. 10/12/2018 Implemented
SIN-00117506 Renewal 07/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)No handrail present on first three steps leading to second floor from kitchen. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The program field manager will ensure that each home that have steps will have a well-secured handrail attached to the wall. The program field manager will also be trained in 6400.73(a) and will ensure on a weekly checklist that each home will be checked and signed off when completed. All staff will also be re-trained on all 6400 regulations so if this were to occur again, it can be reported and replaced as soon as possible. The vice president will train the Program Field Manager and all staff on this regulation 6400.73(a) and will ensure that the entire agency has reviewed this regulation and will be completed by 9/30/17 09/30/2017 Implemented
SIN-00195553 Renewal 11/16/2021 Compliant - Finalized
SIN-00185724 Unannounced Monitoring 04/05/2021 Compliant - Finalized